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LIBRARY OF CONGRESS. 

Chap. Copyright No..__... 

Shell Jp-itJ? 

UNITED STATES OF AMERICA. 



v«-<^^ 



THE DISEASES 



OF THE *' 



MALE URETHRA 



B. W. gTEWART, M.D., M.E.O.S. 

SURGEON TO MERCY HOSPITAL, PITTSBURG, PA. 




NEW YORK 

WILLIAM WOOD AND COMPANY 

-1896 









n^ 



% %i> 



Copyright by 
WILLIAM WOOD AND COMPANT 



:OW DIRECTOR/ 
D BOOKBINDING 
NEW YORK 



CONTENTS. 



CHAPTER I. 

PAGE 

The Anatomy of the Male Urethra, 1 



CHAPTER II. 

Acute Anterior Urethritis (Gonorrhoea). Etiology, „ . . 8 

CHAPTER III. 

Acute Anterior Urethritis. Symptoms and Course, ... 20 

CHAPTER IV. 

Acute Anterior Urethritis. Treatment, ...... 27 

CHAPTER V. 

Chronic Anterior Urethritis. Etiology, 41 



CHAPTER VI. 

Chronic Anterior Urethritis. Pathology, ..... 46 

CHAPTER VII. 

Chronic Anterior Urethritis. Symptoms, . 62 

CHAPTER VIII. 
Urethral Endoscopy, 67 

CHAPTER IX. 
Urethral Mensuration, 78 



iv CONTENTS. 

CHAPTER X. 

PAGE 

Chronic Anterior Urethritis. Treatment, 82 

CHAPTER XI. 
The Posterior Urethra, Ill 

CHAPTER XII. 
Acute Posterior Urethritis. Etiology, 121 

CHAPTER XIII. 
Acute Posterior Urethritis. Symptoms, ..... 126 

CHAPTER XIV. 
Acute Posterior Urethritis. Treatment, 129 

CHAPTER XV. 

Chronic Posterior Urethritis. Etiology ami Pathology, . . . 133 

CHAPTER XVI. 
Chronic Posterior Urethritis. Symptoms and Treatment, . . 137 

CHAPTER XVII. 
Cowperitis, 143 

CHAPTER XVIII. 
The Anatomy of the Epididymis and Seminal Vesicles, . . 149 

CHAPTER XIX. 
Epididymitis, 152 

CHAPTER XX. 
Acute Seminal Vesiculitis, 161 



CONTENTS. v 



CHAPTER XXI. 

PAGE 

Chronic Vesiculitis and Follicular Prostatitis, .... 164 



CHAPTER XXII. 
Stricture of the Urethra. Anatomy, ...... 172 

CHAPTER XXIII. 

Stricture of the Urethra. Etiology, ...... 180 

CHAPTER XXIV. 

Stricture. of the Urethra. Symptoms, ...... 192 

CHAPTER XXV. 
The Location of Strictures of the Urethra, ..... 200 

CHAPTER XXVI. 

Stricture of the Urethra. Treatment of Strictures of Small Calibre, 203 

Index, . .... 219 



INTRODUCTION. 

It may be justly asserted that in no part of the human 
frame does an accurate conception of its structure and 
functions have so important a bearing on the proper un- 
derstanding of its diseases as in the urethra, and it may 
be said with equal justice that in no other part of the 
human frame have such erroneous anatomical and patho- 
logical views been so obstinately maintained. 

Until recent years the medical profession has failed to 
apply to the urethra the same sound reasoning, based on 
a knowledge of pathology, which has been applied to 
other parts of the body. This is partly attributable to 
the fact that during life the facilities for examining the 
urethra have been imperfect, and the opportunities for 
examining it after death have been neglected ; and partly 
to the dogmatic views on the subject which have been 
taught by recognized authorities, and accepted, like 
gospel truths, more on the faith in the infallibility of 
the teacher than on the exposition by these views of ob- 
scure points in urethral diseases. 

With the advent of improved instruments for intra- 
urethral inspection, together with the general advance- 
ment in our knowledge of bacteriological and pathologi- 
cal subjects, a new era in urethral pathology has been 
ushered in and many radical advances have been made, 
not only in the pathology but also in the treatment of 
urethral diseases. 



Vlll INTRODUCTION. 

It will be the object of tlie writer to place before the 
reader the diseases of the urethra, as viewed from the 
modern standpoint, promising, however, that those facts 
relating - to the subject that are too well established to 
be open for discussion will be dwelt upon as briefly as is 
consistent with their proper elucidation. 

The pathology of stricture and its relationship to gleet 
will be entered into, perhaps more fully than its impor- 
tance would apparently justify ; but to those who are 
familiar with the conflicting views entertained on this 
subject, and the far-reaching influence which such views 
exert on the treatment of chronic urethritis, an apology 
is unnecessary. 

In a work of such limited scope as the present one, 
it is considered advisable to confine it as closely as 
possible to the discussion of the acute and chronic in- 
flammations and stricture of the urethra, leaving out 
the diseases of the urethra that are, on account of their 
rarity, unimportant. It will be necessary, however, in 
order to cover the ground in a satisfactory manner, to 
include a description of the inflammatory diseases of the 
important glands which communicate with the urethra, 
namely, Cowper's glands, the glands of the prostate, 
the epididymis, and the seminal vesicles. 



DISEASES OP THE URETHRA. 

CHAPTEK I. 
THE ANATOMY OF THE MALE UKETHRA. 

The urethra (Figs. 1 and 2) is that portion of the geni- 
to-urinary apparatus that has for its function the convey- 
ance from the body of the urinary and seminal secretions. 
When it is in a state of quiescence, or not performing the 
functions stated, its canal is obliterated, and its mucous 
surfaces retained in apposition by the elasticity and con- 
tractility of the submucous connective and muscular tis- 
sues which surround it throughout its entire extent. At 
certain places the muscular tissues become more mark- 
edly developed than at others, forming distinct bands, 
having particular functions to perforin, and deserving of 
the closest attention, since a knowledge of their situa- 
tion and function is essential to the understanding of 
many of the phenomena of urethral diseases. The vesi- 
cal orifice of the urethra is surrounded by a ring of in- 
voluntary non-striated muscular fibres, the tonic contrac- 
tion of which, acting as a sphincter, offers a barrier to 
the passage of urine from the bladder. This muscle is 
called the sphincter vesicae interims. Numerous longi- 
tudinal muscular fibres of the bladder pass into the sub- 
stance of the prostate gland, to become continuous with 
its muscular structure. 



2 DISEASES OF THE URETHRA. 

These muscular fibres radiate from the vesical orifice 
of the urethra along' the vesical wall, and by their con- 
traction during- the act of urination tend to open the ori- 
fice of the urethra, and are, therefore, antagonistic to the 



Promon 




1/1$ eusjjr 
penis 



Praeputl-un 
Qlana penis 



Pig. 1. — Sagittal Section of the Male Generative Organs (Hitzmann). 



action of the sphincter vesicae internus. The two well- 
marked muscular bands which form the lateral bounda- 
ries of the trigone are especially active, their contraction 
tending to open the vesical orifice at their prostatic ter- 
mination and closing the orifice of the ureters at their 



Verteco 




Glans penis 



OrificJcutan. 
Fig. 2.— The Urethra and Bladder Opened from Above (Hitzmann). 



4 DISEASES OF THE URETHRA. 

vesical termination, thus saving- the delicate ureters and 
secreting- portion of the kidneys from injurious disten- 
tion during the act of urination. When the bladder is 
distended the tension of its wall acting on the vesical 
orifice of the urethra overcomes the sphincteric action of 
the internal sphincter, and the urine leaks into the pos- 
terior urethra, which in this condition virtually forms a 
portion of the bladder, and for this reason is often called 
the neck of the bladder (Fig. 3). The further progress 
of the urine is barred by the sphincteric action of two 
muscles surrounding the urethra at, and immediately in 
front of, the apex of the prostate gland. The first is called 
the sphincter vesicae externus. It is a band of striated 
and non-striated muscular fibres, situated at the apex of 
the prostate. The second is called the compressor ure- 
thra'. It is a voluntary or striated muscle, and lies be- 
tween the two layers of the triangular ligament, to which, 
and to the ischio-pubic rami on either side, it is attached. 
Weaving itself in various directions— above, below, and 
around the membranous portion of the urethra — it forms, 
with the adjacent circular muscle situated at the apex of 
the prostate, the external sphincter of the bladder. This 
sphincter is much more powerful than the internal 
sphincter, and offers a greater resistance to the passage 
of fluids or instruments. It is therefore the principal 
barrier to the passage forward of the urine from the 
bladder, and to the passage backward of urethral secre- 
tions or injections, and to this fact the clinical division of 
the urethra into an anterior and a posterior portion is 
due. 

Fig. 3 shows the situation of these muscles and the ef- 
fect on the posterior urethra of a distended bladder, the 
empty bladder being represented by the dotted lines. 



THE ANATOMY OF THE MALE URETHRA. 




Fig. 3. — Diagram Showing the Muscles of the 
Posterior Urethra and the Effect of a Dis- 
tended Bladder on the Internal Sphincter. 



The bulbous portion of the urethra is surrounded by 
the bulbo-cavernosus, or ejaculator urinae muscle, which 
plays an important 
role in expelling 1 the 
last drops of urine, 
and in the expulsion 
of the seminal fluid 
during ejaculation. 
By contracting on 
the extremely vas- 
cular bulb it sends 
a vascular impulse 
forward through the 
lacunae of the cor- 
pus spongiosum, which, in its course, by closely approx- 
imating the urethral wall, empties its canal. 

The muscular tissue of the pendulous portion is unim- 
portant and need not concern us. 

The superficial cells of the mucous membrane of the 
urethra are long and columnar, with the exception of a 
short distance (5 to 8 mm.) from the external orifice, 
where they are squamous, and where the subjacent mem- 
brane is beset with papillae. The epithelium rests on a 
basement membrane, external to which is a layer of con- 
voluted vascular tissue which is separated from the 
proper substance of the spongy body by a layer of circu- 
lar non-striated muscular fibres. 

The urethra is beset with small racemose glands called 
the glands of Littre (Fig. 4). In addition to these there 
are numerous lacunae of considerable length (10 to 20 
mm.), consisting of a reduplication or infolding of the 
mucous membrane, forming a deep cul-de-sac whose axis 
lies obliquely to the urethra, those in the anterior urethra 



6 



DISEASES OF THE UKETHRA. 



opening toward the external meatus ; those in the pos- 
terior urethra, according- to Belfield, opening- toward the 
bladder. 

On the roof of the fossa navicularis one of these lacunae 
attains enormous dimensions and is called the lacuna 
magna. Its orifice is guarded by a fold of mucous mem- 




FlG. 4.— Section Through a Gland of Littre (Taylor). 

brane which sometimes offers an obstruction to the pas- 
sage of small urethral instruments, which may be de- 
flected into the lacunas instead of passing along the 
urethra. 

Opening into the floor of the bulbous portion of the 
urethra are the ducts, one on either side, of Cowper's 
glands. These two little bodies are compound racemose 
glands. They lie between the two layers of the trian- 



THE ANATOMY OF THE MALE URETHRA. 7 

gular ligament, close to the membranous urethra. Their 
ducts extend forward about one and a half inch, and 
pour a thin viscid secretion into the bulbous urethra. 
The urethral glands and diverticula? are important, from 
a pathological stand-point, owing to the fact that they are 
open to the invasion of the gonococci and from their lo- 
cation are but little amenable to local treatment. It fre- 
quently happens, therefore, that the implication of the 
urethral glands and lacuna? in the gonorrheal process 
perpetuates the disease in a chronic form, and it has often 
been observed that chronic lesions are most apt to be 
found in those portions of the urethra where the lacuna? 
are most numerous. 

Reference has been made to the division of the urethra 
into an anterior and a posterior portion, the dividing 
point being the part grasped by the compressor urethra?. 
There are good anatomical, and still better clinical, 
reasons wlw we should adopt this division. These 
reasons will be brought out more fully in the body of the 
work, and, therefore, it will be unnecessary to enter into 
the subject here, further than to say that the anterior ure- 
thra comprises that portion which extends from the com- 
pressor urethra forward to the meatus, and that the pos- 
terior urethra comprises that portion which extends 
from the compressor urethra? backward to the bladder. 

It is presumed that the reader is familiar with the ana- 
tomical divisions of the urethra into prostatic, membran- 
ous, bulbous, and pendulous portions, and therefore no 
description will be necessary when reference is made to 
these anatomical divisions. 



CHAPTEE II. 
ACUTE ANTERIOR URETHRITIS (GONORRHOEA). 

Etiology. 

The mucous membrane of the urethra is singularly well 
protected from atmospheric infection or climatic vicissi- 
tudes. It is not like the mucous membrane of the respira- 
tory tract, exposed to the passage through it of air which 
is unstable in temperature and often laden with patho- 
genic micro-organisms. Nor like the alimentary tract is 
it exposed to mechanical or chemical irritants and the 
presence of decomposing material. Yet in spite of the 
fact that Nature has shielded it most carefully from ex- 
trinsic sources of infection, it is of all the mucous mem- 
branes the one which suffers most acutely from infectious 
diseases. An acute urethritis may be due to any one of 
a number of causes— for instance, mechanical or chemical 
irritation, if of sufficient intensity, will produce an acute 
inflammation of the urethra, the onset of which is rapid, 
reaching its acme in a few hours and subsiding in a few 
days. But this does not explain the cause of the very 
great majority of urethral inflammations which devel- 
op several days after sexual contact, and, for a time, in- 
crease in severity, requiring for their subsidence as many 
weeks as the former variety requires days, and carrying 
with it the property of infectiousness. 

It is but natural, therefore, that this malady, which is 



ACUTE ANTERIOR URETHRITIS (GONORRHOEA). 9 

as old as history and as prevalent as vice, should be at- 
tributed to the growth in the urethra of a micro-organ- 
ism, since it required for its development a period of in- 
cubation, for its acme a definite period representing its 
gradual invasion of the urethra, and a stationary and de- 
clining period of nearly definite limit- 
It would be needless to review the claims that have 
been made at various times for the discovery of the 
micro-organism which produces gonorrhoea, each of 
which were in turn discarded, until, in 1879, Neisser an- 
nounced the discovery of a diplococcus, called after its 
discoverer the gonococcus of Neisser, which he proved 
was the direct cause of the disease. The presence of this 
micro-organism has been constantly shown in the acute 
infectious inflammations and in all chronic inflammations 
of the urethra that retain infecting properties. Its pres- 
ence has also been demonstrated in gonorrhoea! ophthal- 
mia, in ophthalmia neonatorum, in the secretions of gon- 
orrhoeal vaginitis and endometritis, also in the pelvic 
inflammations of the female that are of gonorrhoeal ori- 
gin. It is doubtful if the gonococci will flourish in the 
mucous membrane of the nose or mouth, but they have 
been detected in the rectum in cases of gonorrhoeal proc- 
titis and in the synovial fluid of joints affected with gon- 
orrhoeal rheumatism. In addition to the demonstration 
of the gonococci in the tissues affected with gonorrhoeal 
inflammation, cultures of the gonococci have been made 
and gonorrhoea has been produced from these cultures, 
even when the twentieth generation has been inoculated 
in the urethra. 

So convincing has become the cumulative evidence of 
the causative relationship of the gonococcus of Neisser to 
infectious urethritis or gonorrhoea, that the subject has 



10 DISEASES OF THE URETHRA. 

passed beyond the debatable stage, and all opposition 
lias practically vanished before the arguments and evi- 
dence in its favor. 

"While we may justly concede to the gonococcus the un- 
enviable position of etiological factor in the production 
of gonorrhoea, we will commit an error if we permit it to 
occupy the entire domain in the production of acute ure- 
thritis, for it has been shown by a number of observers 
— and the number is steadily increasing — that other 
micro-organisms than the gonococci may produce ure- 
thral suppuration, and are not infrequently present in 
acute urethritis when the gonococci are absent. It has 
been shown also that the healthy urethra may be the 
habitat of pyogenic micro-organisms that remain inac- 
tive until a favorable exciting cause, that may be non- 
venereal, enables them to assume an aggressive attitude 
toward the urethra. Figs. 5, C, 7, 8, and 9 (after Lust- 
garten) show the micro-organisms that may be found in 
the male urethra. 

It will be seen, therefore, that we may recognize, ac- 
cording to the cause, three forms of acute urethritis. 

First. Acute urethritis due to the growth of the gono- 
cocci in the urethra. This variety comprises the great 
majority of acute urethral inflammations and is remarka- 
ble for the highly infectious nature of the urethral dis- 
charge. 

Second. Acute urethritis due to other micro-organisms 
than the gonococci. These cases usually pursue a milder 
course than the preceding variety, and the discharge is 
either not infectious, or if so, to a very slight extent. 

Third. Acute urethritis due purely to mechanical or 
chemical causes. The discharge from this variety of 
urethritis is not infectious, unless there should be an ac- 



ACUTE ANTERIOR URETHRITIS ''GONORRHOEA). 11 





Fig. 5. 



Fig. 6. 







Fig. 




Fig. 



Fig. 9. 



Figs. 5, 6, and 7. — Micro-organisms of the Normal Urethra. Fig. 5. — a and 
b, Bacilli Resembling Tubercle Bacilli. Fig. 6.— Hyaline Epithelial Cell con- 
taining Streptococci. Fig. 7. — Epithelial Cell containing Pseudo-Gonococcus. 
Fig. 8. — Pure Culture of the latter on Agar. Fig. 9. — Gonococci from Gonor- 
rhoea! Pus : 1-1000 diameters. (After Lustgarten. ) 



12 DISEASES OF THE UKETHKA. 

cidental inoculation of the urethra at the same time with 
pyogenic micro-organisms. 

It will be advisable, however, to consider these varieties 

of urethritis together under the general term of acute 

urethritis, special mention will only be made of each 

/ variety when it is necessary to do so in order to prevent 

confusion. 

The gonococci have but a low vitality and are easily 
destroyed by extremes of temperature, they cannot be 
inoculated in the lower animals, and they will perish if 
exposed to the atmosphere for a time. The sterilization 
of urethral instruments, therefore, offers no great dif- 
ficulty, and the conveyance of a gonorrhoea by such 
means is improbable, if the ordinary precautions regard- 
ing cleanliness are observed. 

The microscopic examination of the urethral secretion 
is of great diagnostic importance, and the genitourinary 
surgeon should be familiar with the methods of staining 

and examining the 

«•:;'&$& gonococci (Figs. 9 and 

.; ^.-..' :; . • •■;»%£0i:ZiZ* 10), which are usually 



t/^'> / rf * * \& fouml in i 3airs > the a P- 

J&ef$\^ ; £. v -'=% proximating surfaces 
/Wjgs.*^- - .': 3;-." ^emg flattened. They 
ft*3#? '^' ^' V^^ He for the most part in 
%*?/ * ** -^ll® the interior of the cells, 

often in such numbers 

Fig. 10. — Gonococci from Gonorrhoeal Pus 

(American Text-book of Surgery). that the Cell is packed 

full of them, but they 

are also found free in the secretion, probably as a result 

of their liberation by the bursting of the gonococci-laden 

cells. 

The method of preparing and examining the urethral 



ACUTE ANTERIOR URETHRITIS (GONORRHOEA). 18 

secretion for gonococci is as follows (Quoted from Hyde 
and Montgomery's " Manual of Syphilis and Venereal 
Diseases," page 363) : 

"In selecting gonorrliceal pus for examination it is 
well to avoid that found at the meatus, as this pus is 
more liable to contain other organisms that might render 
the examination complicated and confusing. It is better 
to obtain pus that may be scpieezed out of a deeper por- 
tion of the urethra. A small drop of this pus is thinly 
spread on a slide or a cover-glass, by means of a plati- 
num wire, or by pressing the drop between two cover- 
glasses and then slipping apart. The thin film is al- 
lowed to dry in the air, and is then fastened to the glass 
by slowly passing- it three times through the tip of the 
flame of an alcohol lamp or a Bunsen burner, the pus- 
covered side being upward. The film is then covered 
with a few drops of the staining fluid, or the cover- 
glass is floated, film side down, on the liquid. The 
preparation should remain in the stain from one to five 
minutes, depending upon the strength of the solution, 
after which the surplus stain is gently washed off with a 
jet of cold water. The specimen can now be examined 
in water or glycerine, or, what is better, it can be dried 
carefully with soft blotting-paper and mounted in Canada 
balsam. 

" The stain employed may be almost any of the basic 
aniline dyes, as methyl-blue, Victoria-blue, methyl-violet, 
gentian-violet, or fuchsin. These dyes may be used in 
aqueous solutions of varying strength, but they do not 
keep well, and it is best to prepare the fluid each time it 
is wanted. This may easily be done by keeping on hand 
a saturated alcoholic solution of the stain, a very small 
quantity of which can be added, drop by drop, to a 
watch-glassful of distilled water until the latter is of the 
required strength and color. The following is a rapid 
and satisfactory method : A solution of methyl-blue is 
prepared by dropping a saturated alcoholic solution of 



14 DISEASES OF THE URETHRA. 

the stain into a watch-glassful of distilled water, or into a 
solution of potassium hydrate (1 to 10,000) until the liquid 
has a dark blue color. The cover-glass, prepared in ac- 
cordance with the above directions, is floated on this 
liquid, pus side down, for from one to two minutes ; it is 
then taken out and the surplus stain is washed off. It 
may now be placed at once, without drying, upon a slide 
and examined, or it may be carefully dried and mounted 
on a slide with Canada balsam. In a specimen thus 
prepared the gonococci appear dark blue, while the cells 
show a very pale blue protoplasm and grayish-blue nu- 
clei." 

While no great difficulty attends the demonstration of 
the gonococci in acute gonorrhoea, the same cannot be 
said in cases of chronic gonorrhoea where the gonococci 
may be absent or may be confounded with other diplo- 
cocci that may be present. Weichselbaum says : 

"It is just as difficult to recognize gonococci in the 
chronic stage of the gonorrhceal inflammation as it is easy 
to do so in cases where the process is quite recent, as in 
the former the specific cocci are present in very small 
numbers, and may be very hard to distinguish from other 
cocci, perhaps occurring along with them (as, for exam- 
ple, in chronic gonorrhceal inflammations of the female 
genital tract), if they har)pen not to lie in the interior of 
the cells. In such cases when examining the living, arti- 
ficial intensification of the process by the injection of a 
weak solution of corrosive sublimate may afford help, 
thus leading to a multiplication of the gonococci while 
the other bacteria are destroyed ; for the purpose of dis- 
tinguishing the gonococci from other cocci, cover-glass 
preparations are first treated by Gram's method and 
afterward stained for five seconds with alkaline methyl- 
blue which has been diluted Avith four times the quantity 
of water, by which means the gonococci are stained blue, 
but the rest of the bacteria blackish. A still more cer- 



ACUTE ANTERIOR URETHRITIS (GONORRHOEA). 15 

tain method, however, in doubtful cases, is to prepare 
plate cultures from the secretion, using- for this purpose 
human serum to which an equal quantity of warm agar 
solution has been added in order to make it solidify." 

The demonstration of the gonococci in the urethral 
discharge stamps it at once as both venereal and infec- 
tious, and establishes indubitably the nature of the dis- 
ease. Yet the microscopical examination for gonococci 
as a diagnostic agent in the differential diagnosis of 
urethral diseases is of less importance than at first sight 
it may seem, and we no longer, as formerly, resort to it on 
all occasions. The reasons for this are the difficulties 
attending bacteriological examinations in general, often 
requiring more experience, facilities, and time than the 
average practitioner can furnish. To this may be added 
the fact that, owing to their resemblance morphologi- 
cally and in their reaction to staining fluids with other 
diplococci found not infrequently in the urethral secre- 
tions, a positive diagnosis cannot always be made even 
where the utmost care is taken, and if such a diagnosis 
is made it is open to the unanswerable criticism that it 
may be inaccurate. Even Neisser admits that about five 
per cent, of the cases where gonococci are diagnosed as 
present are open to doubt and error. 

The only absolute proof of the presence of gonococci 
is by culture and inoculation experiments, and the former 
is too laborious to be practicable, and the latter is obvi- 
ously unjustifiable, since such inoculations must be car- 
ried on in the human urethra, as the gonococci cannot be 
inoculated in the mucosa of the lower animals. 

Another deterrent to the range of usefulness of the 
microscope is the fact that it is in the cases where the 
demonstration of the gonococci are most important that 



16 DISEASES OF THE URETHRA. 

the greatest difficulties are met with, namely, in chronic 
urethral discharges, where the gone-cocci may be in such 
few numbers that it is only after repeated examinations 
that they can be detected. In acute urethritis, where the 
gonococci are abundant and easily demonstrated, the 
clinical features are usually so diagnostic that he who 
runs may rend, and confirmatory evidence obtained by a 
microscopical examination will rarely be necessary. 

It therefore happens that we have settled back to the 
comfortable position of relying chiefly on the clinical 
diagnosis of urethral inflammations, only bringing the 
microscope into requisition when the clinical diagnosis 
is difficult or impossible. 

Acute anterior urethritis, or gonorrhoea, is derived by 
sexual contact with a female suffering from gonorrhoea. 
It is not necessary, however, for the female from whom 
the gonorrhoea is acquired to have the disease in an acute 
form, as she may still retain infecting properties when 
the inflammation has subsided to such a degree as to be 
unrecognizable by inspection. It is not even absolutely 
necessary that she should have the disease in any form, 
for well-authenticated cases are on record where two 
lovers have worshipped at the same shrine, the first, hav- 
ing a gonorrhoea, transmits the disease to the second 
through the medium of the mistress, the latter remaining 
immune. 

There is often a singular tendency among the recipi- 
ents of a gonorrhoea to shield the donor, and to attribute 
its source to less probable causes, such as a sprain, over- 
exertion, wet feet, or alcoholic excesses, while an insinu- 
ation against the virtue of the mistress, or the possibility 
of her sharing her favors is indignantly repelled. On 
the other hand, not infrequently a married man, who is 



ACUTE ANTERIOR URETHRITIS (GONORRHEA). 17 

perfectly faithful to his marital vows, will present him- 
self with all the symptoms of an acute gonorrhoea, and 
bluntly ask you how he came to acquire it. Iu such 
cases considerable tact and diplomacy may be required 
to prevent the incrimination of a possibly innocent 
woman. 

A man may after sexual intercourse acquire a urethritis 
because he himself at some previous time had suffered 
from a gonorrhoea which had apparently disappeared, 
but in reality had lingered in some damaged patch or 
glandular crypt in his urethra, and only required a favor- 
able cause, such* as sexual excess or intemperance, to 
briug on a renewed activity and reinfect the whole ure- 
thra. Or he may be inoculated with other pyogenic 
micro-organisms, such as the staphylococcus or strepto- 
coccus, which may have innocently enough found a habi- 
tat in his own urethra or in the vagina of his partner. 
Such occurrences are probably rare, but that they may 
occur is sufficient warrant for us to give the accused the 
benefit of the doubt, if by so doing we may possibly be 
shielding an innocent woman from a manifest injustice. 

This disease has been innocently acquired from a 
soiled water-closet, or purposely by inoculation, but au- 
thenticated cases of this kind are so rare as to be de- 
servedly ranked among the curiosities of medicine. 

The exposed portion of the meatus is naturally the 
point of inoculation, at which point the gonococci at once 
begin to propagate their kind, and to invade the urethral 
mucosa. It is usually several days before a visible in- 
flammatory reaction results from the invasion of the go- 
nococci. This period is called the period of incubation. 

The incubation period of a gonorrhoea is not a constant 
one, the variations may be dependent on the virility or 



18 DISEASES OF THE URETHRA. 

quantity of the gonococci deposited on the urethra, or 
the more or less favorable condition of the latter to the 
invasion of the micro-organism. 

In thirty-nine cases in which Lanz verified the diagno- 
sis by the demonstration of the presence of gonococci 
the period of incubation was as follows : 

Days. Cases. Days. Cases. 

1 2 8 1 

3 15 ' 10 1 

4 4 ! 14 1 

5 9 j 20 2 

7 4 | 

Taylor has recorded the incubation period in 505 cases 
of first infections as follows : 



Days 

1.. 



Cases 
1 


Days. 

8 


Cases. 

ns 


17 




9 47 


67 


10 


27 


70 


11 


6 


66 


12 


3 


R6 


13 


2 


105 


14 


14 



3 

4 

5 

6 

7 

A gonorrhoea may therefore in exceptional cases ap- 
pear as early as one day or as late as twenty days from 
the period of infection, but the great majority of cases 
have an incubation period of from three to seven days. 
Where the gonococci were placed in the urethra for ex- 
perimental purposes, the period of incubation has been 
from two to three days ; but in these cases we may infer 
that not only a greater quantity of the micro-organisms 
was transferred to the urethra, but also that they were 
placed in more intimate contact with the urethral epithe- 
lium than occurs under ordinary circumstances. 

An acute inflammation of the urethra that is due to 



ACUTE ANTERIOR URETHRITIS (GONORRHOEA). 19 

mechanical or chemical irritation has no period of incu- 
bation, or at most a few hours after the advent of the excit- 
ing cause. Where the inflammation is due to an exacer- 
bation of a previously latent gonorrhoea, the incubation 
period is usually very short, rarely over twenty -four 
hours. All such are, therefore, usually easily differen- 
tiated from acquired gonorrhoea, which has an incubation 
period of several days. 



CHAPTER III. 

ACUTE ANTERIOR URETHRITIS. 

Symptoms and Course. 

The course of a typical uncomplicated case of gonor- 
rhoea is usually as follows : After a period of incubation 
varying' from three to seven daj'S, during which the gono- 
cocci have been propagating* their kind at the point of 
inoculation, and invading the urethra in the immediate 
vicinity, a visible inflammatory reaction is manifested, as 
a slight swelling and hyperemia of the lips of the meatus, 
accompanied with an itching of the parts that may be 
slightly painful during and immediately after urination. 

The gonococci penetrate between the epithelial cells 
lining the urethra, passing to the deepest portion of the 
lacunae and glands of Littre. They may invade the sub- 
mucosa, but are there found in much fewer numbers than 
in the mucosa, for in the former situation they have to 
contend with the free vascular supply of the tissues, 
which furnishes an army of white blood-cells, and if we 
accept the theory of Metsclmikoff, combats the invading 
micro-organisms by taking them up and carrying them to 
the free surface of the urethra ; hence the purulent dis- 
charge so characteristic of the disease. 

The gonococci are propagated between the layers of 
the epithelium, and to a still greater extent on its free sur- 
face, and infect the urethra by a process of extension 



ACUTE ANTERIOR URETHRITIS. 21 

along the surface, and to a lesser extent by extension in 
•the tissues of the urethra itself. It will be seen therefore 
that accidental circumstances, such as injections or in- 
strumental interference, may modify the natural course of 
the disease by carrying the gonococci backward and 
more rapidly infecting the deeper portion of the urethra. 

The theory that has recently been brought forward, that 
infection of the entire urethra takes place almost simul- 
taneously, through the medium of the lymphatics, seems 
scarcely probable, and is opposed to the clinical experi- 
ence of most observers. This theory is advanced to 
strengthen the statement that infection of the posterior 
urethra is so common that it should be considered rather 
as a part of a typical gonorrhoea than as a complication. 
I cannot give support to either the theory or statement, 
but must hold in the light of my own clinical experience 
and investigation, which coincides with that of the major- 
ity of writers on the subject, that infection travels chiefly 
by extension along the free surface of the urethra, and 
that it, in uncomplicated cases, is arrested at the part 
grasped by the compressor urethra?, for the reason that 
at this point the secretions are prevented, by the tonic 
contraction of this muscle, from passing farther backward. 
When infection of the posterior urethra does take place, 
it may be due to the infective secretion being carried 
backward by the use of instruments or injections, or per- 
haps more often by extension of the process beyond the 
external sphincter by continuity of tissue. The fact that 
the membranous urethra is almost devoid of glands or 
lacunae might deter extension by the latter process. 

As a result of the irritation set up by the growth of the 
gonococci in the urethra, inflammatory phenomena are 
manifested, the epithelium undergoes increased prolifer- 



22 DISEASES OF THE URETHRA. 

ation, desquamation may be even more rapid than pro- 
liferation, so that epithelial erosions may be abundant. 
They are chiefly found as minute, almost microscopic, 
ulcerations at the orifice of the lacunae and glands of 
Littre. As a resultant of these changes the urethra is 
swollen, softened, and very vascular, and exudes from its 
free surface a profuse muco-purulent discharge, which 
varies in consistency and color according to the intensity 
of the inflammation and the predominance of the mucous 
or purulent element. The swollen condition of the mu- 
cous membrane diminishes its resiliency, and the stream 
of urine is smaller, while its passage over the inflamed 
and resisting urethra is painful to a degree that may be 
exquisite, especially if the urine is very acid. In very 
severe cases the act of urination may rupture some of 
the engorged capillaries, and be followed by the oozing 
of blood from the urethra. 

Along the under surface of the urethra the inflamed 
glands of Littre may be felt as hard, shot-like bodies. 
Occasionally the orifices of these glands become occluded, 
and the contents, undergoing abscess formation, rupture 
either externally or into the urethra itself. 

The prepuce is frequently oedematous, and on the dor- 
sum of the penis the inflamed lymphatics may be felt as 
a hard cord. The inguinal glands above Poupart's liga- 
ment are usually somewhat swollen and tender, and in 
exceptional cases may undergo suppuration, either from 
the pyogenic properties of the gonococci, or, more prob- 
ably, from a mixed infection, in which the staphylococci 
and streptococci play an important role. 

The above description applies to acute gonorrhoea at 
its acme ; but it must not be forgotten that the disease is 
a progressive one, and that its symptoms vary with the 



ACUTE ANTERIOR URETHRITIS. 23 

intensity and duration of the inflammation. It will be nec- 
essary, therefore, in order to cover the ground to follow 
the clinical aspect of the disease from beginning - to end. 

At the onset of the disease it is only that portion of the 
urethra which comprises the meatus and fossa navicularis 
which is affected. Consequently, while there may be 
marked objective symptoms, the subjective symptoms are 
much less than at a later period, when the disease has 
traversed a greater area of the urethra. In the early 
stage the lips of the meatus are swollen and slightly 
everted, a little purulent discharge exudes on pressure 
from the follicles of the exposed part, but the total dis- 
charge from the urethra is slight. As the disease extends 
backward the amount of the discharge increases, some- 
times to such an extent that it constantly trickles from 
the meatus. The discharge is now thick and creamy, and, 
in very severe cases, it may be of a greenish tinge. The 
disease gradually increases in intensity for about ten 
days, dating from its first appearance, by which time the 
gonococci have invaded the urethra as far as its bulbous 
portion, where, in uncomplicated cases, its progress is 
arrested. At this period the acme of the disease has been 
reached, and another epoch of about ten days is now en- 
tered upon in which the disease is stationary at its point 
of greatest intensity. During this period the whole an- 
terior urethra is tender and swollen, and the discharge is 
thick and abundant. Constitutional symptoms may be 
present in the form of slight febrile disturbance, chilliness, 
and malaise. The patient is tortured at night by erec- 
tions, which, besides aggravating the intensity of the 
inflammation, are exceedingly painful, more especially if 
the spongy tissue surrounding the urethra is infiltrated 
to such a degree as to prevent the filling of its lacunar 



24 DISEASES OF THE URETHRA. 

spaces and extension with the corpus cavernosnm during 
erection, producing a downward curvature of the penis, 
to which the name chordee has been given. The period 
of greatest intensity of the inflammation is followed by a 
gradual decline in the intensity of all the symptoms. 
The discharge lessens in quantity and becomes less 
creamy, and the mucous element gradually predominates. 
The urethra becomes less tender, the pain in urination di- 
minishes or disappears, and the stream of urine increases 
in size. In favorable cases, in from ten to fifteen days from 
the beginning of the period of decline the inflammatory 
symptoms will have subsided, with the exception of a 
hypersecretion of mucus, which may persist for one or 
two weeks as a clear, sticky fluid, which keeps the meatus 
unnaturally moist. 

The above may be accepted as descriptive of the type 
of an acute uncomplicated attack of gonorrhoea. The 
symptoms may, however, be modified by the variability 
in the intensity or virulence of the disease, by previous 
attacks of gonorrhoea, by the presence of a constitutional 
diathesis or dyscrasia such as gout, rheumatism, tubercu- 
losis, or syphilis ; also by the habits and occupation of 
the patient, together with the modifications of the disease 
which may be produced by treatment, or the onset of any 
of the numerous complications which may at any moment 
alter the whole aspect of the case. 

It is a question, therefore, whether there is such a thing 
as a typical gonorrhoea ; or, to put it more specifically, 
which is typical, the complicated or the uncomplicated 
gonorrhoea ? 

Gonorrhoea has been described as a self-limited disease, 
and such is usually the case. To the question why it is 
self-limited we may reply, for the same reason that other 



ACUTE ANTERIOR URETHRITIS. 25 

contagious diseases are limited, namely, the gonococci, 
by their continued growth in the same soil, deprive that 
soil of the materials essential to the maintenance of their 
pristine virility, and in the struggle for existence are 
unable to maiDtain a successful warfare against the 
urethral tissues. 

One attack of gonorrhoea, however, offers no barrier to 
subsequent attacks, although they are rarely as severe as 
the primary attack, but are more liable to be followed by 
unpleasant sequehe. 

In some attacks of gonorrhoea the symptoms are never 
acute at any time, and may be classed as subacute from the 
outset. In these cases it is reasonable to suppose that 
the original infection is either weak from long-continued 
propagation of successive generations of the gonococci 
in the mucous membrane of the vagina, and does not re- 
gain its virility on transplantation to a new culture field ; 
or else that the latter, perhaps from previous attacks of 
inflammation, offers but a poor medium for the growth of 
the micro-organism. 

Doubtless many of the cases of so-called simple ure- 
thritis, which in the older works were attributed to having 
connection with a female who has a leucorrhoea, or has 
not ceased to menstruate, would come within this cata- 
gory of subacute gonorrhoea. 

It is unnecessary to enter into the symptoms and 
course of this variety of gonorrhoea. Suffice it to say 
that it is simply a milder grade than the acute, not only 
in the duration of the attack, but also in the character of 
the discharge and general course of the disease. The 
microscopical demonstration of the gonococci in the dis- 
charge would establish the diagnosis, and should be used 
in case of doubt. 



26 DISEASES OF THE URETHRA. 

It should not be forgotten, however, that some attacks 
of urethritis are not due to the gonococci, but to other 
pyogenic micro-organisms, which are less irritating to the 
urethral mucosa, and are therefore associated with milder 
symptoms, and might be classed as subacute from the 
beginning, although some of these cases pursue a pro- 
tracted course. 

A few words may with advantage be said at this stage 
on acute urethritis not due to parasitic causes. A 
typical illustration of this is sometimes seen where the 
urethra is swabbed or injected with a strong solution of 
nitrate of silver to abort a dreaded attack of gonorrhoea. 
In these cases there is no period of incubation, and the 
acme is reached in a few hours at the utmost, after which, 
without the intervention of a stationary period, the in- 
flammatory symptoms steadily subside ; resolution being 
complete in a few days; and, unlike gonorrhoea, never 
lapses into the chronic stage. The absence of an incuba- 
tion period and the brief duration of the disease, together 
with the history of a mechanical or chemical irritant that 
immediately preceded the attack, will readily differen- 
tiate this disease from true gonorrhoea. It may be more 
difficult, however, to determine whether the attack may 
not be an exacerbation of a latent gonorrhoea, roused 
into activity by a local irritant. In some cases this can 
only be determined by a demonstration of the presence 
or absence of the gonococci. 



CHAPTEB IV. 
ACUTE ANTERIOR URETHRITIS. 

Treatment. 

It must be admitted there has been less progress, in 
recent years, in the treatment of acnte urethritis than in 
any other department of urethral surgery. This has 
certainly not been due to a lack of effort on the part of 
the profession, for they have displayed a most restless 
activity in this line of work, and a review of the litera- 
ture of the subject would be, to say the least, hercu- 
lean. Almost every worker, and some that are not 
workers, in urethral surgery, has at one time or other 
discovered a specific, for which not infrequently prepos- 
terous claims have been based on the experience of one 
or two cases. 

It would seem as if gonorrhoea was constantly on the 
verge of being shorn of its terrors and reduced, if not to 
innocuous desuetude, at least to a par with the pro- 
verbial cold. But frankly speaking, of all the specifics 
that have been from time to time introduced with a hur- 
rah, not one has stood the test of time and experience, 
and the treatment of this malady is simply where our 
fathers left it. 

We have learned by bitter experience to be more con- 
servative than formerly. We are less prone to adopt 



28 DISEASES OF THE URETHRA. 

heroic methods of treatment, and we probably real- 
ize more fully the treacherous nature of this disease ; 
how it may at any moment strike off at a tangent and 
lead us into the gravest of situations ; and we have 
come, therefore, to respect it accordingly. In this there 
is a distinct advance, but it is a passive, not an ag- 
gressive one. 

In the following- pages the writer has nothing new to 
suggest, and simply states what his own experience, 
backed up by that of conservative writers on the subject, 
warrant him in giving as the safest and most satisfactory 
method of treatment. This may serve to explain the ap- 
parent incompleteness and also the dogmatic tone of this 
chapter, both of which are necessary in order to steer 
clear of the pitfalls of verbosity and vagueness which 
often ensnare a writer on a subject on which so much 
literature has been wasted. 

In the treatment of an acute gonorrhoea the physician 
should strengthen his position by impressing on the 
patient the necessity of conforming to the rules laid 
down to govern his conduct, and the care of his ure- 
thra ; and also to impress upon him the uncertainty and 
treacherous nature of the disease. He should not permit 
either himself or his patient to look lightly upon it, for 
the simplest case may prove most intractable to treat- 
ment, or be followed by the most troublesome complica- 
tions. 

The treatment of acute urethritis is hygienic, dietetic, 
and therapeutic. The following fundamental rules 
should form the basis of treatment in all cases. A life of 
repose or abstinence from extreme muscular exertion 
should be advocated. If a patient would only consent to 
remain in bed he would be under the best possible con- 



ACUTE ANTERIOR URETHRITIS. 29 

ditions for recovery ; but it would be unreasonable to ask 
liim to submit to confinement during- an uncomplicated 
attack of gonorrhoea ; besides, motives of secrecy would 
usually interpose an effectual barrier to such a proceed- 
ing. However, he should avoid unnecessary exertion or 
exposure ; he should keep regular hours, retire early, 
and avoid all female society that might tend to produce 
erotic feelings. 

A non-stimulating diet should be followed. By this is 
meant the avoidance of highly seasoned food, which is 
liable to excite the sexual organs. Tea and coffee should 
be used but sparingly, but their total elimination I do 
not think either necessary or advisable. Bland liquids, 
such as milk or water, should be drunk freely, in order to 
dilute and render the urine less irritating to the inflamed 
urethra. 

Alcoholic drinks in any form should be forbidden. 

This is all-important and must be carried out to the 
letter if we desire to obtain the best results. If it is 
impossible to totally abstain from alcoholic drinks, the 
only thing permissible would be to take a glass, and the 
more seldom the better, of the dark or red wines, as the 
astring-ent principle in these wines serves to counteract 
their irritating properties. Many patients fancy that 
they may indulge in beer because of the scantiness of its 
alcoholic constituents, but it has been my experience 
that this is the very worst drink that a patient with a 
gonorrhoea can take, and its use should be rigorously 
tabooed. 

The bowels should be regulated. Constipation and 
diarrhoea are each injurious. Absolute cleanliness of the 
genital organs by frequent ablutions should be enforced. 
The hands should be carefully washed after touching the 



30 DISEASES OF THE URETHRA. 

parts, and infection of the eyes carefully guarded against, 
otherwise the results may be disastrous. 

The therapeutic treatment of gonorrhoea may be di- 
vided into two classes of remedies, hist those that 
are administered by mouth, and second, those that are 
applied directly to the inflamed urethra by injec- 
tions. 

The first class may be in turn subdivided into two 
groups, namely, those such as the alkalies that have only 
a local action, by rendering the urine unirritating in its 
passage through the urethra, and those, such as the fixed 
and ethereal oils, which seem to have a twofold action, 
first by impregnating the urine and thereby exerting a 
local action on the urethra during urination, and second, 
by a direct or specific action on the mucous membrane. 
It has been shown that injections of the latter group of 
remedies have a beneficial influence on the inflammatory 
process, but are not as efficacious in this way as by in- 
ternal administration, from which it may be inferred that 
these remedies exert a beneficial influence on the inflamed 
urethra, not only while passing in the urine, but also be- 
fore their elimination, while circulating in the tissues of 
the urethra. 

To the first group of remedies belong the alkalies, 
which act by directly neutralizing the acidity of the 
urine. The alkalies in most common use are the citrate 
of potassium, the bicarbonate of potassium, and liquor 
potass*. The writer frequently uses a tablet containing 
potassium and sodium bicarbonate, each five grains, one 
tablet to. be taken every two hours until the urine is 
nearly neutral in reaction. The alkali should not be ad- 
ministered immediately after or before a meal as diges- 
tion may be interfered with in so doing. Nor should the 



ACUTE ANTERIOR URETHRITIS. 31 

remedy be pushed to the point of making- the urine 
distinctly alkaline, as such urine is of itself irritat- 
ing and may precipitate phosphatic crystals that act 
as a mechanical irritant in its passage through the 
urethra. 

To the same class of remedies belong diluents, which 
tend to render the urine, by diluting it, less irritating to 
the urethra. 

The representatives of the second group of remedies 
are sandal-wood oil, copaiba, and cubeb. Sandal-wood 
oil is probably the most elegant preparation, as it is less 
liable to nauseate than the others. The great objec- 
tion to it is its cost, and the consequent liability to adul- 
teration. 

Copaiba is the remedy in most general use. It is just 
as efficacious as any other, and its cheapness is a guar- 
antee of its purity. It will, however, in some cases pro- 
duce an aching over the kidneys, and occasionally a tran- 
sient albuminuria. In this relation it should be borne in 
mind that copaiba is eliminated in the urine as sodium 
copaivate, and on the addition of a mineral acid to the 
urine the copaiba is liberated from the soda and precipi- 
tated as copaivic acid, which forms a whitish flocculent 
precipitate soluble in an excess of the acid, and may be 
readily mistaken for albumin. Copaiba will also in some 
cases produce an erythematous eruption that may be the 
cause of considerable alarm to the patient. The erup- 
tion, however, is harmless, and will rapidly subside on 
the withdrawal of the remedy. 

Cubeb is in less repute than sandal-wood or copaiba, 
but it is still frequently used in powder, fifteen to fifty 
grains at a dose, or in combination with one or other of 
the remedies already mentioned. 



32 DISEASES OF THE URETHRA. 

Subjoined are given some of the most popular combi- 
nations of these remedies : 

Lafayette Mixture. 

1. 
IJ . Copaibae, 

Spiritus lavenduke compositi, 

Spiritus astheris nitrosi, 

Liquoris potassa? aa f § ss. 

Olei gaultherise f 3 ij. 

Mucilaginis acacia' f § vj. 

M.— Sig. : One to two teaspoonfuls three times a day, after meals. 

A modification of the above, one that I frequently use, 
is as follows : 



IJ . Copaibae f 3 vj. 

Liquoris potassa? f 3 iv. 

Olei gaultherise f 3 .1- 

Extractum glycyrrhizse 3 ij. 

Mucilaginis acacia-, q. s. ad \ vj. 

M. — Sig. : Two-drachm dose to be taken two hours after meals. 



R. Olei santali f § ss. 

Olei menth. pip gtt. viij. 

M. — Sig. : Fifteen to twenty drops to be taken after meals. 

4. 
5. Pulveris cubeba?, 

Copaibas aa f § ss. 

Acacias 3 ij. 

Aquas cinnamomi f 3 iv. 

Syr. aurantii cort f § j. 

M. — Sig. : One-drachm dose to be taken after meals. 

Dr. J. William White speaks very highly of salol in 
the treatment of acute urethritis, and recommends the 
following formula given in capsules : Salol, 5 gr. ; oleo- 
resin of cubebs, 5 gr. ; Para balsam of copaiba, 10 gr. ; 
pepsin, 1 gr. He says further: "While I do not think 



ACUTE ANTERIOR URETHRITIS. 33 

that ' complete cures ' are often obtained by internal rem- 
edies alone, I have become entirely convinced that the 
administration of this capsule is of great benefit in re- 
ducing- both the severity and duration of infectious ure- 
thritis, and of lessening the frequency of occurrence of 
posterior urethritis and its complications." 

It is unnecessary to pursue this line of prescribing 
farther. The combinations are infinite, and the reader 
may be safely left to modify or add to them as he sees fit. 
Any or all of them may prove disappointing, and the 
best of them are unpalatable. It would seem as if Nat- 
ure had purposely punished the sin of venery by fur- 
nishing only the most nauseating drugs for its relief. 

The local treatment consists in the use of injections. 
An instrument should never be passed along the acutely 
inflamed urethra unless it is for the relief of a greater 
evil, such as retention of urine or the treatment of an in- 
flamed posterior urethra, which may be necessary in 
order to relieve vesical tenesmus. 

While there is a fairly uniform sentiment among phy- 
sicians that the internal administration of remedies 
should be begun as soon as a gonorrhoea is recognized, 
there is still the greatest diversity of opinion not only 
as to the value of urethral injections, but, to a still greater 
extent, as to the proper time to use them. Some decry 
their use at any period ; others insist on their use from 
the beginning of the disease, but the majority of urethral 
surgeons, the writer among the number, advise that the 
use of injections be deferred until the declining period 
of the disease has been reached. 

When it was proven that gonorrhoea was caused by a 
parasitic growth in the urethra, a host of surgeons 
adopted the use of antiseptic irrigation, and much injury 



34 



DISEASES OF THE URETHRA. 



was done by the use of bichloride of mercury solutions, 
ranging in strength from 1 to 1,000 to 1 to 5,000. Subse- 
quently weaker solutions, 1 to 15,000 to 1 to 30,000 were, 

and are still em- 
ployed, an apparatus 
such as is shown in 
Fig. 11 being used. 
A few still claim that 
the disease is mate- 
rially shortened by 
this plan of treat- 
ment, which prom- 
ised so much in the- 
ory but accomplished 
so little in results. 
There are potent rea- 
sons why antiseptic 
solutions do not ex- 
terminate the gono- 
cocci. First, the rem- 
edy cannot be used 
in sufficient strength, 
on account of its ir- 
ritating properties, 
to have much germicidal action ; and second, the gon- 
ococci have the power of burrowing out of reach, as 
it were, of the antiseptic solution, which, if suffi- 
ciently strong to be germicidal, coagulates the albu- 
min on the surface of the urethra, which interposes an 
effectual barrier to the deeper penetration of the in- 
jection. In addition to this the treatment is trouble- 
some, requiring frequent irrigation of the urethra, and 
judged from the stand-point of results it scarcely repays 




Fig. 11. — Irrigation Apparatus. 



ACUTE ANTERIOR URETHRITIS. 35 

for the trouble it entails. Besides, it is a method of 
treatment that is prone to be followed by posterior ure- 
thritis, with its unfortunate sequelae of cystitis, epididy- 
mitis, etc. 

As has already been stated, it is the firm conviction of 
the writer, and in this he voices the sentiments of the 
majority of urethral surgeons, that injections should not 
be used in the treatment of acute gonorrhoea until the 
period of decline of the disease has been entered upon. 
At this period the gonococci have reached their farthest 
limits along the urethra, therefore the injection will not 
likely be the means of propagating 'the disease by wash- 
ing the micro-organisms backward. Besides, the period 
is now entered upon when the urethral tissues begin to 
exercise their supremacy over the gonococci, which are 
forced to the free surface where they may be advantage- 
ously attacked. 

The technique of injecting is of some importance. A 
syringe, such as is shown in Fig. 12, capable of contain- 
ing half an ounce, should be used . The nozzle should 
be bluntly tapered so as to block the orifice of the ure- 
thra. Before injecting, the patient should urinate in 
order to cleanse his urethra. The syringe, filled with the 
injection, should be inserted into the meatus so as to 




Fig. 12. — Injection Syringe. 

block the return of the fluid. The injection should be 
gradually forced into the urethra until a feeling of dis- 
tention is experienced, similar to that felt on sudden- 
ly blocking the stream during urination. The syringe 



36 DISEASES OF THE URETHRA. 

should then be withdrawn, and the injection retained for 
from two to three minutes. The injection may be re- 
peated as often as is considered advisable, but no injec- 
tion should pain or burn for a longer period than ten 
minutes. 

The number of injections in common use are multi- 
tudinous, and it would be a work of supererogation to 
attempt to enumerate them, as the list would be inter- 
minable and their combinations infinite. Almost every 
physician, and for that matter many of the laity, have 
their own favorite injections. The following are given 
by the writer, not necessarily as the best, but as the ones 
from which he has obtained the most satisfactory results : 

1. 

R. Extracti hydrastis fluidi f § j. 

Zinci sulphatis gr. xx. 

Morphinae sulphatis gr. iij. 

Aquae rosac, q. s. ad f § vj. 



R. Zinci sulphatis, 
Ferri sulphatis, 

Alumini sulphatis 55. gr. xij. 

Cupri sulphatis gr. vj. 

Aquae destillat&\ q. s. ad f § vj. 

3. 

R. Zinci sulphatis gr. xv. 

Plumbi acetatis gr. xxx. 

Aquae rosae f § vj. 

Tincturae catechu, 

Tincturae opii aa. f 3 j. 

4. 
R. Zinci sulphatis, 

Aluminis pul veris aa.gr. xij. 

Acidi carbolici gr. iv. 

Aquae destillatae, q. s. ad f 1 vj. 



ACUTE ANTERIOR URETHRITIS. 37 

5. 

B . Potassii perrnanganatis gr. iv. 

Aquae destillatae, q. s. ad f § vj. 

6. 

B . Argenti nitratis gr. iij. 

Aquae destillatae, q. s. ad f § vj. 

7. 

B . Zinci sulphocarbolatis gr. xxiv. 

Aquas destillatae, q. s. ad f § vj. 



B . Hydrarg. chlor. corrosivi gr. £. 

Zinci sulphocarbolat 3 ss. 

Acid, boric 3 ij. 

Acid, carbolic f 3 £. 

Boroglyceride (twenty-five per cent. ) f ? ij. 

Aquae destillat f § iv. 

Sig. : Use locally ; dilute if painful. " Useful as the first injection in 
tbe beginning of the stationary period." — Dr. J. William White. 

The multitudinosity of the injections in common use is 
proof positive that none of them are always efficacious. 
I have often, in my own practice, observed the progress 
of a gonorrhoea untreated by injections, at any period of 
its course, and frequently found it to compare favorably 
with cases where I have used injections freely. I do not 
attempt to decry the use of injections in acute gonor- 
rhoea, but simply state that there are cases of gonorrhoea 
that do just as well without them. On the other hand, 
the contrary more often holds good, and the physician 
himself can be the only judge of what to do in any par- 
ticular case. 

When the erections are troublesome, especially if pol- 
lutions are frequent, they seriously hinder the favorable 
progress of the disease, and treatment should be directed 
to control them. 



38 



DISEASES OF THE URETHRA. 



Lupulin and the bromides are the most efficacious reme- 
dies at our disposal. The following prescriptions will 
usually be satisfactory : 

1. 

R . Potassii bromidi § j. 

Aquae camphorse f | iv. 

M. — Sig. : A tablespoonful to be taken at bedtime. 



R . Lupulini gr. xx. 

Morphinae sulphatis gr. jss. 

M.— Ft. capsulas, No. 10. Sig.: One capsule to be taken night and 
morning. 

It would be well for the patient to sleep on a hard bed, 
and with scanty clothing- ; also to bathe his penis in warm 
water before retiring, and with the onset of erections to 
get up and urinate. 

In my own practice the routine treatment of an uncom- 
plicated case of gonorrhoea is usually as follows : The 
patient is first instructed concerning the hygienic and 

dietetic rules he is to fol- 
low as indicated in this 
article. He is advised to 
drink liquids freely, the 
alkaline mineral waters, 
such as Yichy or Bethes- 
da,are recommended, and 
the evils of alcoholic 
drinks are explained to 
him. He is ordered to 
wear a suspensory band- 
age with a gonorrhceal 
bag attachment (Fig. 13), which can be procured at any 
drug-store. He is then given a prescription containing 




Fig. 13. — Suspensory with Gonoirhoeal 
Bag-attachment. 



ACUTE ANTERIOR URETHRITIS. 39 

copaiba, preferably a modification of the Lafayette mixt- 
ure (No. 2) ; also a prescription for a drachm dose of 
bromide of potassium in camphor water, to be taken at 
bedtime, if necessary, to control erections. 

If the patient bears the medicine well, he is kept on it 
until the stage of decline is' well established. If his 
stomach rebels against the medicine a simple alkaline 
mixture is substituted, and in addition capsules of sandal- 
wood-oil may be given. In the stage of decline, under any 
circumstances, I simply use an alkaline mixture, or give 
the alkaline mixture between meals and the copaiba mixt- 
ure at bedtime. If the case does well under this treat- 
ment injections are withheld until I am dissatisfied with 
the progress of the case. Then I usually try Eicord's in- 
jection (No. 3), substituting some of the others if I see fit. 
If the gonorrhoea under this treatment becomes station- 
ary, without pain and with but little discharge, I use 
weak injections of nitrate of silver (No. 6), or else pass, 
for a few times at intervals of three days, one or two full- 
sized sounds that have been cooled in ice-water before 
introduction. In case this failed to effect a cure I would 
be inclined to abandon all treatment for a time. Its re- 
sumption, if necessary, would come under the treatment 
of chronic urethritis. The cure of gonorrhoea is often de- 
layed by over-anxiety, or over-activity in its treatment, and 
will often progress more favorably if permitted for a time 
to pursue its own course toward recovery. 

A few words may here be said on the abortive treat- 
ment of gonorrhoea, which was formerly so much vaunted. 
This method has been thoroughly tried and found want- 
ing, and is but little in vogue nowadays. Ill results are 
oftener met with in its use than beneficial ones, and the 
conservative physician will scarcely of his own accord 



40 DISEASES OF THE URETHRA 

advise a treatment that will in all probability fail of its 
object, and by aggravating- the course of the malady 
bring down the censure of the patient. Even if used at 
the urgent solicitation of the patient, it should only be 
done under protest, and with a full recognition by the 
patient that he must assume all responsibility for the re- 
sult. 

The method in common use is one or more strong 
injections, of nitrate of silver, ten or thirty grains to the 
ounce. This is always followed by a marked inflamma- 
tory reaction ; but in some cases the disease is shortened 
or possibly aborted. The pain of such an injection may 
be mitigated by injecting a week saline solution, or by 
directing the patient to urinate. A better plan is to in- 
sert an endoscopic tube, thoroughly cleanse the mucous 
membrane, and swab its surface with a solution of nitrate 
of silver, thirty to sixty grains to the ounce. Strong in- 
jections of bichloride of mercury have been used to abort 
a gonorrhoea, but its use for this purpose is now aban- 
doned. The physician will steer clear of many rocks if 
he avoids the abortive treatment of gonorrhoea. 

It is a common supposition that injections, especially 
if strong, will produce stricture. Such has not been the 
experience of the writer, nor can I see how a stricture 
will follow an injection unless we can conceive of its be- 
ing strong enough to devitalize a portion of the urethral 
mucous membrane, when a traumatic stricture might re- 
sult from the formation of cicatricial material in the re- 
parative process. 



CHAPTER V. 
CHKONIC ANTEEIOR UKETHRITIS. 

Etiology. 

Chronic inflammation of the urethral canal differs from 
the acute form of the disease chiefly in that it is of a 
lesser degree of intensity, and that it shows a greater 
tendency to become localized to certain areas in the 
urethra, which, at the parts affected, undergo structural 
changes, having but scant inherent tendency to return to 
a normal condition. The antecedent history and chief 
etiological factor in the production of chronic anterior 
urethritis is usually that of an acute anterior urethritis 
or gonorrhoea, and the more intense it has been, the 
greater the tendency to the formation of chronic lesions. 
Simple urethritis, such as may be caused by a strong in- 
jection, irritates the urethra to a lesser extent than a 
specific or gonorrhceal urethritis, and is a much less im- 
portant factor in the production of chronic urethral dis- 



Not infrequently we see cases of urethritis that are sub- 
acute or chronic from the beginning, and frequently 
pursue an obstinate course. Many of these cases are in 
urethrse that have already suffered from attacks of gonor- 
rhoea, and in these cases we may infer that the gonococci 
implanted in a urethra which had previously been the 
culture-field for previous generations of gonococci are 



42 DISEASES OF THE UKETIIRA. 

unable to find sufficient pabulum for a vigorous growth. 
In other cases where there has been no antecedent gonor- 
rhoea it may be presumed that the gonococci, from long- 
continued growth in the previous culture-field, have but 
little virility ; or else we may presume that the inflamma- 
tion is due to some other less virulent micro-organism, 
or to syphilis, tuberculosis, or some such cachectic con- 
dition. 

An acute urethritis may be said to have passed into the 
chronic stage when, after the lapse of sufficient time for 
the subsidence of the disease under ordinary circum- 
stances, the discharge does not cease, but exists as a scant, 
thin, muco-purulent discharge. This may appear as the 
morning-drop, or there may only be a stickiness, with 
adhesion of the lips of the meatus, or the patient may be 
only able to detect an abnormal secretion by the perni- 
cious practice of milking or stripping his urethra. 

An interesting problem for solution is why an acute 
urethritis which is due to an infectious process does not 
end in spontaneous recovery. AVhy is it that in some 
cases the gonococci disappear and the infectious process 
terminates within definite limits (four to six weeks), 
while in others the process may be continued in a chronic 
form indefinitely, and its infectiousness retained for a 
prolonged period? In attempting to answer this ques- 
tion we must bear in mind that there is a continual war- 
fare going on between the gonococci and the urethral 
tissues, and the result is simply a question of the survival 
of the strongest. In the early stage of the contest the 
gonococci have the advantage because they are trans- 
planted upon a fresh culture-medium, where the condi- 
tions are favorable to their growth. As the disease pro- 
gresses the repeated propagation of the gonococci, 



CHRONIC ANTERIOR URETHRITIS. 43 

through successive generations in the same culture-field, 
weakens their vitality, and the balance of power is turned 
in favor of the urethral tissues. At the same time the 
symptoms of the disease diminish in intensity, and termi- 
nate with the ultimate extermination of the micro- 
organism. 

It will be seen, therefore, that any factor which lowers 
the vitality of the urethral tissues diminishes its power 
of antagonizing the gonococci, and predisposes to the 
j)rolongation of the disease. Prominent among these 
factors are, in the order of their importance, intemper- 
ance, sexual indulgence, violent or prolonged exertion, 
exposure to sudden climatic changes, and a constitutional 
diathesis or cachexia, such as syphilis, tuberculosis, gout, 
and rheumatism. 

In some cases the acute disease will pass into the 
chronic stage where none of these predisposing factors 
can be determined as being present. It will usually be 
found in such cases that the patients are subject to catar- 
rhal affections ; that the mucous membranes of the body, 
the urethra included, are peculiarly susceptible to the 
inroads of disease, and exhibit a corresponding tardiness 
in returning to a healthy condition. 

Chronic urethritis is, as a rule, limited to certain well- 
defined areas, the remainder of the urethra being usually 
in a healthy condition, except, when from an exacerbation 
of the existing inflammatory disturbance, the secretion 
from the inflamed areas, pouring over the otherwise 
healthy urethra, sets up a catarrhal inflammation in the 
latter. 

It is difficult to explain why certain areas of the urethra 
should undergo complete and prompt recovery from a 
gonorrhceal inflammation, while a contiguous area, ana- 



44 DISEASES OE THE URETHRA. 

toinically identical, and endowed, as far as we can judge, 
with equal resisting power to the invasion and growth of 
the gonococci, should nevertheless become the permanent 
habitat of the latter, and undergo, as a result, structural 
changes to which the healthy areas are exempt. In the 
present status of the pathology of chronic urethritis this 
problem cannot be solved in a perfectly satisfactory 
manner. 

It is a matter of common observation that chronic in- 
flammations of the urethra are most often found in the 
deeper portions of the canal, so that we may state, as a 
general rule, to which of course there are many excep- 
tions, that the nearer to the vesical orifice of the urethra 
the greater the liability to the presence of chronic lesions. 
When we consider that the proximal portion of the ure- 
thra is the part first and often most severely affected in 
acute inflammations, and also that it is liable to be bathed 
in the secretions of the distal portions of the anterior 
urethra, the reverse of which does not hold true, it may 
seem curious that chronic inflammations are least liable 
to be found in this situation. The frequent localization 
of the inflammatory process in the bulbous urethra has 
been variously attributed to imperfect drainage, owing to 
its more or less horizontal position and the consequent 
liability to infiltration of its walls. It has also been com- 
pared to a suppurating pouch, probably under the sup- 
position that in gonorrhoea the secretions accumulate 
and distend this very dilatable portion of the canal. 

We can scarcely accept either of the above hypotheses 
as correct when we consider that this portion of the ure- 
thra is surrounded by a special muscle, the ejaculator 
urinae, for the purpose of emptying the canal, at the same 
time it draws attention to the fact that the muscular irri- 



CHRONIC ANTERIOR URETHRITIS. 45 

tability of the part, by disturbing- its quiescence, may be 
a factor in the prolongation of the inflammatory process. 
There are other reasons, however, that may better serve 
to explain this phenomena, namely, the difficulty that at- 
tends, from its situation, the local treatment by injections 
of this portion of the urethra, and also, what is of more 
importance, it is the bulbous part of the urethra that is 
most freely supplied by glands and lacuna? in which the 
gonorrheal process is so prone to lurk. This is sup- 
ported by the fact that the membranous portion is very 
poorly supplied by these diverticula?, and it is also very 
little liable to become the seat of chronic inflammatory 
lesions. 

The frequency of chronic inflammation in the posterior 
urethra will be explained in the chapter devoted to its 
diseases, and need not be entered into here. 



CHAPTER VI. 
CHKONIO ANTERIOR URETHRITIS. 

Pathology. 

A proper understanding of the pathological changes in 
chronic urethritis is indispensable not only as the basis 
on which to form a guide to the rational treatment of the 
disease, but also on account of its bearing in determin- 
ing the disputed relationship between stricture and gleet. 

The pathology of chronic urethritis is so intimately as- 
sociated with the pathology and formation of stricture, 
and must overlap each other to such an extent, if a sep- 
arate description were given, that no attempt will be 
made to divorce them. Much, therefore, of the following 
must be considered as applying more directly to stricture 
than to chronic urethritis, and will be subsequently util- 
ized in the consideration of stricture. 

To Finger, of Vienna, belongs the credit of placing the 
pathology of this disease on an accurate and scientific 
basis. His post-mortem macroscopical and microscopi- 
cal examinations of numerous cases of chronic urethritis 
have such an important bearing on the subject that I will 
quote freely from his work as follows : * 

"The hyperemia, serous swelling, and infiltration, 
which are observed with the endoscope so often during 

* Blennorrhcea of the Sexual Organs, by Ernst Finger. Third edition, page 
171 et seq., Anatomo-pathological Changes of the Pars Anterior. 



CHRONIC ANTERIOR URETHRITIS. 47 

life, either disappear post mortem or become less recog- 
nizable. 

" There are, however, numerous macroscopic changes. 
The epithelium exhibits changes which vary from slight 
opacity to considerable thickening and whitish discolor- 
ation ; the latter condition often simulates superficial 
cicatrices. Losses of epithelium are much rarer than 
thickenings and are usually superficial and isolated. / 
never found extensive erosions or ulcerations. 

" The changes in the subepithelial tissue, the swelling 
and infiltration which depend upon hyperemia, are in- 
distinct on account of the disappearance of the hyper- 
emia. Only one group of cases exhibited changes of the 
surface which were due to swelling. In circumscribed 
spots the surface appeared finely ridged, uneven, contain- 
ing small nodules, whose size varied somewhat. These 
were undoubtedly granulations, as was shown by the mi- 
croscopical examination. 

"There were striking changes in Morgagni's lacunas. 
On section of the normal urethra these are invisible, or 
appear as very fine dots. In a series of cases of chronic 
urethritis the openings are as large as the head of a pin, 
and with the surrounding parts may be elevated like a 
crater. In another group of cases the lacunae are absent, 
and they are replaced by milky-white nodules which are 
embedded in the mucosa. 

" With the unaided eye it is often impossible to dis- 
tinguish cicatrices from simple epithelial thickenings. 
This is particularly true of ridge- and net-shaped, slightly 
elevated strictures, which are formed in part by the epi- 
thelium, in part by subepithelial connective tissues. 

" Non-constricting, depressed, eccentrically retracted 
callosities are not infrequent. Examination shows that 
they are always very superficial and due to changes in 
the uppermost layers of the subepithelial tissue. 

" There are numerous interesting microscopical changes. 
In a series of cases the epithelium still retains its normal 
arrangement, but the uppermost layer of cylindrical cells 
is loosened and in a condition of mucoid degeneration. 



48 DISEASES OF THE URETHRA. 

The transition cells, consisting- normally of one or two 
rows, are often spread over many rows. Numerous pus 
corpuscles are embedded between the cylindrical and tran- 
sition cells. Another interesting- change is the transition 
of cylindrical into pavement epithelium. Three types of 
pavement cells may be distinguished : 

" (a) It resembles that of mucous membranes with pave- 
ment epithelium — i.e., it consists of an undermost layer of 
cubical cells, several layers of polygonal cells, and an 
upper layer of pavement epithelium. 

" (b) The epithelium is epidermoidal, consists of a lower 
layer of cubical cells, followed by several layers of poly- 
gonal or spindle-shaped cells analogous to the rete Mal- 
pighii ; these cells constantly grow larger and flatter 
toward the surface. 

" (c) The epithelium is like that over cicatrices, and 
consists of several layers of very flat pavement epithe- 
lium. 

" This conversion of cylindrical into pavement epithe- 
lium, which causes a xerosis of the mucous membrane, is 
connected with the changes in the subepithelial connec- 
tive tissue. Thus the first type of cells is found over re- 
cent round-celled infiltration, the second type over older 
ones, the third form over firm connective tissue. 

" The subepithelial connective tissue exhibits the most 
important changes, and is the site of the chronic inflam- 
matory process proper. This consists of an infiltration 
of the connective tissue, which has a decided tendency to 
transformation into retracting connective tissue. In the 
more recent cases we find that the subepithelial connec- 
tive tissue, sometimes only in the upper layers, some- 
times extending even into the corpus cavernosum, con- 
tains a loose or dense infiltration, consisting of mononu- 
clear and epithelioidal cells, sometimes mixed with pus 
cells. This infiltration surrounds the lacuna? and glands 
embedded in the subepithelioidal tissue ; hence it is also 
perilacunar and periglandular. 

" In a group of cases the cellular infiltration contains 
numerous, evidently new-formed, very wide blood-vessels. 



CHRONIC ANTERIOR URETHRITIS. 49 

These two factors — viz., the infiltration and the blood- 
vessels — give to the subepithelial connective tissue that 
papillomatous appearance, that mulberry-like condition 
of the mucous membrane in places which we described 
as granulations. The infiltration consists of round and 
epithelioidal cells ; as it grows older the spindle cells be- 
come more abundant, the interfibrillary tissues become 
denser and firmer, and there finally results a tissue which 
resembles a cicatrix anatomically. It is not due to ulcer- 
ation, but to chronic connective-tissue hyperplasia. The 
granulations which may have formed during the recent 
stage are flattened by the retraction, and a callosity re- 
sults. This corresponds to the infiltration of the first 
stage ; it is always circumscribed, sometimes located su- 
perficially in the uppermost layers of the subepithelial 
connective tissue, sometimes it extends deeply, even into 
the corpus cavernosum. 

" The stag'e of infiltration and cicatrization may be 
complicated temporarily by exacerbation of acute inflam- 
mation and emigration of leucocytes. 

" The lacunae exhibit changes analog-ous to those in the 
mucous membrane. The epithelium shows desquama- 
tion of the cylindrical cells, proliferation of the tran- 
sition cells, transformation into pavement epithelium. 
The infiltration in the perilacunar tissues often raises 
the lacunae and dilates their lumen. If the infiltration 
in the connective tissues retracts, the lacunae will become 
atrophic and disappear. Not infrequently the outlet is 
first narrowed, and the lacunas is then converted into a 
little cyst filled with pavement epithelium. 

" Littre's glands, which are situated in the meshwork 
of the corpus cavernosum, exhibit two kinds of changes. 
In one the change is periglandular ; the small-celled in- 
filtration of the subepithelial connective tissue around 
the excretory ducts of the glands draws them downward 
and surrounds the glands and its duct. The excretoiy 
duct also exhibits epithelial changes which imitate those 
found upon the free surface, viz., the three types de- 
scribed above. Special interest attaches to the second 



50 



DISEASES OF THE URETHRA 



type, in which the epithelium resembles that of the rete 
Malpighii. This is developed excessively in the excre- 
tory ducts, even extends into the body of the gland, 
pushes beneath the secreting glandular epithelium and 
leads by compression to destruction of the acini. The 
secreting epithelium merely exhibits passive changes, 
viz., destruction by the periglandular infiltration, which 
penetrates into the net-work of the acini. 




%%M0r~9 



FlG. 14. — Section through a Stricture, the Connective- tissue being so firm as 
to resemble cicatricial tissue. (Taylor.) 



" Exacerbations of acute inflammation, with emigration 
of pus corpuscles, can also be demonstrated in the glands 
and their excretory ducts. 

" In a number of cases the corpus cavernosum is en- 
tirely intact. It may also take part in two ways in the 
chronic inflammatory process. 

" In one series of cases the chronic infiltration remains 
in the main superficial. It only enters the corpus caver- 
nosum along the excretory duct and around the bodies of 
Littre's glands. This periglandular infiltration com- 
presses not only the glands, but the adjacent spaces of 



CHRONIC ANTERIOR URETHRITIS. 51 

the corpus cavernosum are also drawn into the retrac- 
tion. The corpus cavernosum then appears to be trav- 
ersed by an entire series of cicatricial connective-tissue 
bands. 

"In another series of cases the chronic infiltration, 
which occupies the entire thickness of subepithelial 
periurethral tissue, also penetrates the corpus caver- 
nosum ; here it remains superficial or occupies its entire 
width. In the first stage of the small-celled infiltration 
the trabecule of the corpus cavernosum appear enlarged 
and infiltrated with numerous round (later spindle) cells. 
If this infiltration, which is always circumscribed, under- 
goes retraction the mucosa and corpus cavernosum are 
converted into a firm, retracting callosity. These deep- 
spreading callosities are the causes of stricture. 

"Wasserman and Halle (1891) have confirmed these 
findings, and we are therefore warranted in defining 
stricture as the result of chronic cirrhotic periurethritis 
and cavernitis, which complicate chronic urethritis. 

" Hence we must distinguish in the pars anterior two 
forms of the chronic process: a purely mucous, super- 
ficial form, which results in superficial non-constricting, 
eccentrically retracting cicatrices ; and a second form, in 
which the process extends to the periurethral tissue and 
corpus cavernosum, and thus leads to stricture." 

On page 111 of the same work there appears the fol- 
lowing : 

" So long as the process remains localized in the 
mucous membrane these are the symptoms which may 
persist for years. That such a chronic urethritis, situ- 
ated solely in the mucous membrane, may heal as the re- 
sult of recovery of the spot of infiltration by the formation 
of connective tissue and superficial cicatrices I have proved 
by post-mortem examination. When the process extends to 
the submucous tissue, to the corpus cavernosum, and the 
chronic itifiltration heals by the formation of retracting con- 
nective tissue, a new and gradually developing symptom of 



52 DISEASES OF THE URETHRA. 

a more serious significance is added to the clinical history, 
viz., narrowing or stricture." 

The pathology of chronic urethritis, as portrayed by 
Finger, sheds considerable light on the formation of 
stricture. Many questions remain unanswered, and 
there is still much that is obscure, but the recent ad- 
vances in this line of study are most encouraging and 
give promise that urethral pathology will soon be estab- 
lished on a scientific basis. The chief point of interest 
that the subject- has is the relationship of granular ure- 
thritis to stricture. An effort will be made to prove that 
granular urethritis is not only the forerunner, but the 
prime etiological factor, in the production of the great 
majority of strictures of the urethra ; and by the same 
proof to demonstrate the fallacy of the theory, so gener- 
ally accepted, that stricture bears a relationship to gleet 
of cause and effect. 

It will be necessary, however, to enter somewhat in de- 
tail into the subject of granulations, and also, in so doing, 
avail ourselves of the results of investigations, not only 
in the urethra but also in the conjunctiva, where we fre- 
quently find a similar condition present, and where the 
disease is easily studied, and since the well-known course 
of the latter will be utilized to corroborate the state- 
ments concerning the less-known course of the former, 
it may be advisable to establish their relationship at the 
outset. 

A granular urethritis is the result of a gonorrhoeal in- 
fection of the urethra. This is so well recognized that it 
is no longer a subject for discussion, and may therefore 
be passed over without further mention. On the other 
hand, a granular conjunctivitis is, in the vast majority of 
instances, derived by contact with a similar case of gran- 



CHRONIC ANTERIOR URETHRITIS. 53 

ular conjunctivitis. It is well known that a single indi- 
vidual with this disease may infect a whole community, 
as is sometimes witnessed in asylums, schools, and bar- 
racks. A case of granular conjunctivitis always gives 
rise by transmission to a similar conjunctivitis, but it is 
now generally recognized that this it not the only source 
of the malady, for it has been shown that a gonorrhceal 
conjunctivitis may be followed, as in the urethra, by the 
formation of granulations, which in its turn may perpetu- 
ate the latter disease. 

The following extract bearing on this subject is from 
Dr. Ernst Fuch's "Text-book of Ophthalmology," page 77 
et seq. : 

" Does any connection exist between trachoma and 
acute blennorrhcea ? 

" These two diseases, which both originate in infection, 
are, of course, in their typical form, very different from 
each other. Nevertheless, the chronic blennorrhcea which 
develops from an acute blennorrhcea is so similar to the 
papillary form of trachoma that these two cannot be dis- 
tinguished from each other with certainty, either by the 
clinical examination of the eye or by anatomical dissec- 
tion. 

" We may advance the following hypothesis : Recent 
acute blennorrhcea when transferred to another eye pro- 
duces blennorrhcea in the latter also. But if the acute 
blennorrhcea has already passed into the chronic form, its 
transfer to another eye is no longer an acute but a chronic 
inflammation, which latter is trachoma. Different obser- 
vations speak for the possibility of such a method of 
origin of trachoma. Goldzieher reports an epidemic of 
trachoma in the school for the blind at Budapest, an epi- 
demic which had been introduced by a new-comer, a boy 
who had lost his sight from acute blennorrhcea. Through 
him all the male and most of the female scholars became 
affected with trachoma, all possible forms of which, in- 



54 DISEASES OF THE URETHRA. 

eluding the pure papillary, the pure granular, and the 
mixed, could be recognized." 

Sattler has observed the following case : 

" A mother, who was affected with leucorrhcea, gave 
birth to a child having acute blennorrhcea of moderate 
degree. The mother acquired a genuine trachoma by in- 
fection from her child. As she lived in a region perfectly 
free from trachoma, infection from any other source was 
excluded. Against such a connection between chronic 
blennorrhcea, following the acute form, and trachoma, the 
objection has been raised that in the former disease gran- 
ulations (lymphatic follicles) have never been observed. 
But this is not always the case. In the autumn of 1887 
two girls, sisters, were admitted to my clinic, the elder of 
whom had acquired an acute blennorrhcea of the con- 
junctiva of both eyes as a consequence of her own leucor- 
rhcea. The younger sister had caught the infection from 
the eyes of the elder, and likewise acquired acute blen- 
norrhcea of both eyes. In her case this was not quite so 
severe in its onset, and, after the greatest violence of the 
inflammation had abated, papillary outgrowths developed 
in the conjunctiva tarsi, and numerous granulations in 
the folds of transition, so that there was presented a per- 
fect picture of mixed trachoma. 

" In many other cases besides this I have been able to 
observe the development of granulations in the folds of 
transition after acute blennorrhcea, and still more fre- 
quently have been able to prove their existence by the 
microscopical examination of excised portions of the 
conjunctiva. 

" From what has preceded we may draw the following 
conclusions : There is but one kind of trachoma, which, 
however, appears under various forms. The ultimate 
origin of the disease is probably referable to the secre- 
tion of genitals affected with gonorrhoea. This secretion 
produces in the human conjunctiva acute blennorrhcea, 
which passes into chronic blennorrhcea. The secretion 



CHRONIC ANTERIOR URETHRITIS. 55 

of the latter produces in a healthy eye directly a chronic 
inflammation, trachoma, which then by a repeated pro- 
cess of transfer spreads of itself." 

The first manifestation of a granular urethritis is a 
round-celled infiltration of the subepithelial tissues. 
This infiltration may be limited to the mucous mem- 
brane or it may penetrate deeper, invading- the submu- 
cous and cavernous tissue. The infiltrating- cells tend to 
become heaped in clumps directly under the epithelium. 
New blood-vessels penetrate the infiltration, ramifying in 
the subepithelial clumps, giving to the urethra so af- 
fected the florid, papillary appearance so characteristic 
of granulations. 

At a later stage the infiltrating cells become trans- 
formed into spindle cells and ultimately are converted 
into dense retracting connective or cicatricial tissue, 
while, pari passu, the epithelium of the affected portion 
passes from the columnar to the pavement variety. 

The contraction of the cicatricial tissue gradually 
strangulates the exuberant vascular supply of the granu- 
lation tissue, the affected area becoming as anaemic as it 
was previously plethoric. At the same time it gradually 
changes in color from florid to pale or pearly white. By 
this means Nature, by a process of substitution, cures the 
disease, for not only does the conversion of granulation tis- 
sue into cicatricial tissue obliterate the former, but in addi- 
tion the gonorrheal virus, or exciting cause of granula- 
tions, disappears, and its further propagation is rendered 
impossible. 

It should be borne in remembrance that the conversion 
of granulation into cicatricial tissue is a slow process, re- 
quiring months, or even years, for its completion, and 
may be more advanced at one part than another. Side 



56 DISEASES OF THE URETHRA. 

by side may frequently be seen all gradations, from the 
florid, papillary surface of recent granulation tissue to the 
pale, dense cicatricial tissue of the completed process. 

While we cannot but admire Nature's method of work- 
ing out a cure in these troublesome cases, we must ad- 
mit that it is an evidence that she sometimes bungles in 
her handiwork, for she relieves one malady by the sub- 
stitution of another, often of more serious import, name- 
ly, the replacement of granulation tissue by cicatricial 
tissue. 

It often happens that this is a matter of no impor- 
tance, as when limited areas of the mucous membrane 
alone are involved, resulting in superficial callosities 
which do not produce an appreciable diminution of the 
urethral calibre. When the cellular infiltration involves 
not only the mucous membrane, but also the submu- 
cous and cavernous tissue, the resulting transformation 
into retracting connective tissue may produce serious 
changes in the lumen of the urethra, varying from slight 
coarctations to almost total occlusion. 

From what has been said about the analogy of the dis- 
ease as it appears in the urethra and conjunctiva, we 
would naturally infer that they would pursue a similar 
course, namely, the cure of the disease by the conversion 
of granulation into cicatricial tissue. This is just what 
happens in the conjunctiva, where the resulting cicatri- 
cial contraction frequently produces, as in the urethra, 
marked deformity of the affected parts. 

Now that we have considered stricture and its causes, 
a similar, though much briefer, exposition of gleet and its 
causes will be necessary before we can establish, in a sat- 
isfactory manner, the relationship of the two diseases. 

Gleet has been defined by Hunter, Cooper, and other 



CHRONIC ANTERIOR URETHRITIS. 57 

authorities, as an imperfectly cured gonorrhoea. This 
definition deals with the cause of the disease, and is open 
to the criticism that it is scarcely broad enough in its 
scope, since there are undoubtedly cases of gleet that are 
not gonorrhceal in origin. 

Gleet is a chronic muco-purulent discharge which es- 
capes from the meatus as the morning-drop, and is less 
noticeable, or may be absent, during the day, when the 
urethra is frequently flushed during urination. The dis- 
charge in certain low grades of urethral inflammation 
may be muco-purulent and scant from the beginning. 
The terminal stage of a gonorrhoea is also mucopurulent, 
but we do not apply the term gleet to such cases unless 
they become chronic. 

The constituents of the gleety discharge are mucus, 
pus, and epithelial cells, the proportion of each varying 
with the varying conditions of the urethra. An exuda- 
tion of mucus free enough to escape from the meatus is 
not always pathological, as it may be witnessed in an 
otherwise healthy urethra under intense sexual excite- 
ment. This is, however, but transitory and has no rela- 
tionship to gleet. 

The proportion of pus cells depends somewhat upon 
the intensity of the inflammatory disturbance. In a gen- 
eral way we may say, the more marked the inflammation 
the greater the proportion of pus cells, while the prepon- 
derance of epithelial over pus cells is an indication of the 
favorable progress of the disease. The frequent micro- 
scopical examination of the discharge is therefore of some 
value from a prognostic point of view. 

A gleety discharge is an indication of a low grade of 
urethral inflammation, although the absence of a visible 
discharge is not necessarily a proof of the absence of a 



58 DISEASES OF THE URETHRA. 

localized or latent urethritis, as the secretion may be too 
scant to appear at the meatus, although it is visible as 
urethral or pus threads in the recently voided urine. The 
inflammatory origin of gleet is universally conceded ; 
the only debatable question that may arise concerns its 
source, whether from a catarrhal or a granular urethritis, 
or from ulceration of the mucous membrane. Repeated 
endoscopic examinations have shown the frequency and 
often the association of the two former processes, while 
the same method of examination has shorn ulceration of 
its terrors and relegated it to a very minor position in the 
category of urethral ills. We may, therefore, safely say 
that a gleety discharge has for its source certain areas of 
the urethra which are in a state of chronic catarrhal or 
granular inflammation, and that both of these processes 
are frequently present at the same time, while gleet due 
to ulceration (by this term is meant ulcers of the urethra 
so large as to be easily perceptible on ocular inspection) 
is so rare that for all practical purposes it may be 
ignored. 

It is unnecessary to go into further detail on the sub- 
ject of gleet. Its relation to stricture, to which much of 
the foregoing has evidently led up, will next receive con- 
sideration. The relationship of stricture and gleet, ac- 
cording to Otis, is simply one of cause and effect. In the 
light of the pathology of stricture, as shown in this ar- 
ticle, the arguments on which this statement is based 
will not bear investigation. If gleet is a symptom or re- 
sult of stricture it necessitates the priority of existence of 
the latter ; but it has been shown that stricture tissue is, 
in the great majority of cases, the terminal stage of a 
granular urethritis, and it has also been shown that gleet 
is one of the earliest symptoms of a granular urethritis ; 



CHRONIC ANTERIOR URETHRITIS. 59 

therefore the impossibility of establishing- the priority of 
stricture is evident. A gleety discharge is often observed 
in simple catarrhal inflammations of the urethra when 
there is neither a granular urethritis nor a stricture 
present. 

A stricture resulting from a gonorrhoea does not mani- 
fest itself until the lapse of months, and often years, after 
the inception of the gonorrhoea. Guyon collected 142 
cases of stricture with the view of ascertaining the length 
of time that elapsed between the appearance of stricture 
and the first attack of urethritis. He found that in 

4 cases it occurred within one year. 
10 " " " " two years. 

36 " " " between the second and fourth years. 

19 " " " " the fourth and sixth years. 

24 " " " " the sixth and eighth years. 

49 " " " from ten to fifteen years later. 

It is a matter of common observation that the gleety 
stage of a gonorrhoea is usually well established in a much 
shorter period, all of which is contrary to what we should 
expect were the latter a symptom of the former. Were 
stricture the cause of gleet, we should naturally expect 
that in those cases that remain untreated the progres- 
sively increasing obstruction to the stream of urine pro- 
duced by the continuous contraction of the stricture 
would in like ratio tend to aggravate the gleety discharge. 
On the contrary, it is a very general rule that the gleety 
discharge progressively diminishes and usually ultimately 
disappears, notwithstanding that the stricture may be 
more evident than ever. Even the most ardent disciples 
of Otis must concede what from their stand-point must 
seem inexplicable, namely, that a gleet is more com- 
monly associated with those soft, recent coarctations of 



60 DISEASES OF THE URETHRA. 

slight degree called strictures of large calibre, than with 
the long-standing dense strictures of smaller calibre. 
This can be readily explained when we consider that the 
conversion of granulation tissue into cicatricial tissue 
obliterates the former, so that when cicatrization is com- 
plete the granulations with their gleety manifestation 
have disappeared. 

Another argument that may be adduced to support the 
above is the fact that traumatic strictures are not neces- 
sarily associated with gleet at any stage of their forma- 
tion, because this variety of stricture has not, as an etio- 
logical factor, a preceding granular urethritis. 

The genito-urinary surgeons who maintain the depend- 
ence of gleet upon stricture have unfortunately made the 
mistake of placing the cart before the horse ; or, to put it 
more accurately, they have placed two results of the 
same disease in the false relationship to each other of 
cause and effect. What is gleet but the muco-purulent 
discharge resulting from a chronically inflamed urethra ? 
What is stricture but the connective-tissue transformation 
of the cellular elements of a granular urethritis into cica- 
tricial tissue? 

The following deductions on the causation of stricture, 
and its relations to gleet may be drawn from the forego- 
ing : 

1. Strictures are more frequently caused by gonorrhoea 
than by all other causes combined. 

2. Strictures due to gonorrhoea are, in the majority of 
cases, secondary to the formation of granulation tissue. 
The latter is caused by the long-continued growth and 
localization in certain patches of the urethra of the gon- 
orrhceal virus. 

3. Granulation tissue in its early stage is one of the 



CHRONIC ANTERIOR URETHRITIS. 61 

most common sources of gleet. Its ultimate conversion 
into cicatricial or stricture tissue destroys its gleety man- 
ifestation, so that by the time the process of cicatrization 
is complete the gleety discharge has disappeared. 

4. Gleet is an early manifestation, while stricture is a 
later manifestation, of granulation tissue, but owing to 
the process of cicatrization being only partially complete 
they are usually associated with each other. Complete 
cicatrization obliterates the former and perpetuates the 
latter. 

5. The relationship of stricture and gleet is therefore 
not one of cause and effect. They are only related in so 
far as they may be derived from the same source. The 
evidence produced that stricture may cause or perpetuate 
a gleet is not supported by recent pathological investi- 
gation. 

6. The depth to which the granulation tissue has in- 
vaded the urethra determines the degree of the stricture. 
If it is confined to the mucous membrane, superficial cal- 
losities are formed which do not obstruct the urethral 
canal. If the cavernous tissue is invaded, true stricture 
is produced. 



CHAPTEE VII. 

CHEONIC ANTERIOR URETHRITIS. 
Symptoms. 

Chkonic anterior urethritis is manifested by a slight 
gleety discharge, which may be noticed as the morning- 
drop, or may be observed during the day by squeezing 
the urethra. In many cases the only thing perceptible 
is a gluing of the meatus, due to the inspissation of the 
exuded mucus. Not infrequently the discharge may be 
so slight as to escape the patient's observation, so that he 
may fancy that he is free from urethral disease, although 
an examination of the urine at this time will show the 
presence of characteristic urethral threads, which are 
never found when the urethra is in a perfectly healthy 
condition. 

If the urine is passed into two vessels, the first part will 
in its passage along the urethra cleanse the latter of the 
mucus, pus, and epithelial debris that line its surface. 
The second vessel will contain the urine that has passed 
over a cleansed urethra, and will be free from these ele- 
ments unless there should be an associated inflammation 
of the deep urethra, bladder, or of the ureters or pelvis 
of the kidney. During an exacerbation of the urethritis 
the first urine will contain mucus, pus, and epithelial 
debris, in considerable abundance ; but during the period 
of quiescence, when the discharge is slight, only the 




CHRONIC ANTERIOR URETHRITIS. 63 

gonorrhceal threads may be present. These are noticed 
as little, threadlike bodies, varying in size and consis- 
tency, and are distinguished from mucus or semen, for 
which they may be 
mistaken by their 
firmer consistency 
and greater specific 
gravity, rapidly sink- 
ing to the bottom of 
the vessel while the 
latter float for a 
time near the surface. 
A microscopical ex- 
amination (Fig. 15) 
shows these threads 

to consist Of muCUS, fig. 15.— A so-called Gonorrheal Thread, con- 
DUS and eoitlielial sisting of Pus Corpuscles and Urethral Epi- 

thelium. (Ultzmann.) 

cells, rolled into 

threadlike bodies in a similar manner to the epithelial 
rolls formed by rubbing the cutaneous surface after a 
bath. The gonorrhceal threads are formed by the urine 
in its passage over the urethra, rolling the secretion 
adhering to its surface into these threadlike bodies 
and expelling them in the first part of the urine. Dur- 
ing the treatment of chronic urethritis the progress of 
the case may be judged by observing these threads ; a 
diminution in their number and size indicating a corre- 
sponding diminution in the inflammatory process. It 
should be remembered, however, that the number of 
these threads will depend somewhat on the length of 
time that has elapsed since the previous urination, as 
the longer the interval the greater the amount of secre- 
tion that will accumulate in the urethra, and hence the 



04 DISEASES OF THE URETHRA. 

more numerous the pus threads. Frequent microscopical 
examinations of these threads, by determining- the pro- 
portion of pus and epithelial cells, will indicate the 
progress of the case. A preponderance of epithelial 
cells indicates that the disease is progressing toward 
recovery. 

A characteristic symptom of chronic urethritis is the 
exacerbations that frequently ensue on the slightest pro- 
vocation. A patient, under the impression that he is 
perfectly free from the disease because of the disappear- 
ance of the discharge, takes advantage of the license his 
apparent cure may give him, when lo, on the following 
morning there is a profuse purulent discharge. He is 
prone under these circumstances to fancy that he has 
contracted a new gonorrhoea, and believes that he is pe- 
culiarly susceptible to the disease, since every venereal 
contact is followed by a purulent discharge. The ex- 
acerbation subsides in a few days, whether treated or un- 
treated. If the former, the patient usually attributes 
his rapid recovery to the use of some favorite injection, 
and carries the prescription around with him as a spe- 
cific for the cure of gonorrhoea, citing his own case as 
proof of its efficacy. These are also the cases in which 
sonic physicians bombastically laud their ability to cure 
a gonorrhoea in from two to five days. 

"What has taken place may be explained by the fact 
that the patient has a damaged urethra, certain areas be- 
ing in a condition of latent granular or catarrhal inflam- 
mation. Any indiscretion, such as sexual congress -or 
intemperance, sets up an active inflammation in the dam- 
aged areas, the discharge from which, passing over the 
otherwise healthy portions of the urethra, sets up an 
acute but transitory inflammation of the latter, which is 



CHRONIC ANTERIOR URETHRITIS. 65 

manifested by the escape of a purulent discharge that 
may contain gonococci. 

The theoiy that these exacerbations are produced by 
reinfection by gonococci which have found an abiding- 
place in some damaged portion of the urethra, and owing 
to the lowered vitality of the urethral tissues are enabled 
to temporarily resume the activity which repeated cult- 
ures in the same soil had deprived them of, will not ap- 
ply to all cases, but is probably the best explanation that 
at the present time can be given, and is supported by 
the fact that the gonococci, which may have almost dis- 
appeared during the period of quiescence, are usually 
found in abundance in the discharge of the exacerbation. 
If these exacerbations are due to reinfection of the ure- 
thra by the gonococci liberated from the damaged areas, 
their vitality and ability to penetrate the mucosa must be 
much weakened, for the resulting inflammatory disturb- 
ance subsides in a few days and the urethra is rapidly re- 
stored to its previous condition. We may infer that the 
lightness of these recurring attacks is not wholly due to 
the additional resisting properties that the urethral tis- 
sues may have acquired from repeated infection, from 
the fact that the same urethra, if infected by gonococci 
from external sources, will pass through a nearly typical 
course of gonorrhoea. 

A symptom frequently met with in chronic urethritis, 
as well as in the terminal stage of an acute gonorrhoea, 
is a peculiar, uneasy, ill-definable sensation, due to a 
hypersensitive condition of the urethra, which is in- 
stantly, but temporarily, relieved by the benumbing effect 
of the passage of a sound. Lancinating pains, which for 
want of a better name may be called neuralgia, sometimes 
shoot along the urethra, terminating in the glans penis ; 



66 DISEASES OF THE URETHRA. 

this, however, is more frequently met with in diseases of 
the posterior urethra. 

Frequency of urination is not a symptom of chronic 
anterior urethritis, but there may be a slight tingling 
pain in the act. In the exacerbations of the inflamma- 
tion, urination, if the urine be acid, may be quite painful. 

The patient who has a chronic urethritis will often 
complain that after he has urinated, and apparently com- 
pleted the act, a few drops of urine will escape from the 
urethra and soil his clothes. This is due to the fact that 
the urethra, as a result of chronic infiltration, is sclerosed, 
and does not immediately collapse on the termination of 
the act, but remains for a few moments as a more or less 
rigid tube, until the elasticity of the urethra overcomes 
its rigidity, when the urethra collapses and the contained 
urine dribbles from the meatus. 



CHAPTEE VEIL 
UEETHRAL ENDOSCOPY.* 

The localization of chronic urethritis to distinct areas, 
where, as a result, gross pathological changes are mani- 
fested, requires for its proper treatment not only that we 
should be able to apply the remedial agents to the 
affected areas, but also that we should, first of all, be able 
to inspect the urethra, in order to determine the nature 
and situation of the morbid processes which we desire to 
treat. For this purpose we resort to the use of the endo- 
scope, by which we are able to inspect the urethra under 
artificial illumination. 

Desormeaux, who is deservedly called the father of 
endoscopy, was not the first to use the endoscope, but 
was the first to bring it into practical use. His instru- 
ment, introduced in 1853, was, however, clumsy, and only 
permitted of inspection of the urethra. Since then the 
endoscope has been variously improved and simplified, 
until it is now a very satisfactory instrument. Some of 
the endoscopes at present in use permit only of the in- 
spection of the urethra ; but only those that permit of 
local applications to the urethra during inspection need 
be considered, as all others fail in the most useful part of 
the instrument. Only a few of the numerous endoscopes 

* This chapter on Urethral Endoscopy, and the following chapter on Urethral 
Mensuration, are inserted here because a knowledge of these subjects is essential 
to the proper understanding of the treatment of chronic urethritis. 



es 



DISEASES OF THE URETHRA. 



will be described, and of these the reader may be safely 
left to make his own selection. 

Gruenfeld reduced the instrument to its simplest pro- 
portions. His instrument (Fig-. 16) consists of a simple 
tube, with its vesical extremity blocked with an obturator 




Fig. 16.— Gruenfeld's Endoscope. 

to facilitate its introduction into the urethra. The ocular 
extremity is funnel-shaped to facilitate the passage of the 
rays, and the interior of the tube is darkened to prevent 
the reflection from its surface interfering - with the field of 
vision. Klotz found that a perfectly polished interior did 
not interfere, but rather made the field of vision clearer, 
and further improved Gruenfeld's instrument by sub- 
stituting a flange for the funnel-shaped extremity, which 
prevents painful distention of the meatus, and by enabling 




Fig. 17. — Klotz's Endoscope. 

the operator to crowd the instrument into the urethra a 
shorter tube can be used and the field of vision therefore 
brought nearer to the eye. 

With the instrument of Gruenfeld or Klotz the light is 
reflected by a head-mirror into the endoscopic tube after 
the manner in which the laryngologist examines the 
larynx, the light may be either a McKenzie lamp or an 
incandescent electric light. It requires a little experience 



URETHRAL ENDOSCOPY. 69 

to enable the operator to focus the light properly on the 
field of vision, but when once it is acquired it is a very 
satisfactory method of using- the endoscope. 

The next form of instrument carries a small electric 
lamp fixed to the instrument, so that the field of vision is 
under constant illumination. The best-known type of 
this instrument is the Leiter instrument (Fig-. 18), or the 
modification that has been made by Otis (Fig. 19). Haw- 
kins has devised an endoscope on similar lines that cer- 
tainly gives good illumination. These instruments are, 
however, unnecessarily clumsy, and they require a battery 
or current reducer, the lamps barn out, the batteries get 
out of order, and the wires are often a nuisance, so that I 
would recommend the beginner to accustom himself to 
the simple tube and head-light of the Gruenfeld or Klotz 
instrument. 

A still more complicated endoscope is the one devised 
by Oberlander and improved by Kollman, in which the 
source of light is at the distal extremity of the instru- 
ment, close to the field of vision. While this instrument 
gives excellent light the space taken up b\ r the wires and 
the necessary cooling apparatus seriously interferes with 
its usefulness ; besides, it is a very cumbersome appara- 
tus, and is, on the whole, only superior to the other sim- 
pler instruments in impressing the patients, and is de- 
cidedly inferior to them in point of usefulness. 

Yan Antel invented an instrument for examining the 
urethra while the latter is distended with air, but as only 
a portion of the urethra can be examined by this instru- 
ment, and as the portion that can be examined is ren- 
dered anaemic, by the distention, the value of the in- 
strument is but very slight. Fenwick has devised a 
urethroscope on the same principle as Van Antel's in- 




& 



URETHRAL ENDOSCOPY. 71 

strument, but uses the electric light for the purpose of 
illumination. Various long urethral speculums have 
been devised for examining the urethra, but they are 
chiefly useful in the removal of papillomatous growths 
or to facilitate the cutting of strictures near to the 
meatus. 

For the endoscopic examination of the urethra tubes 
ranging in size from 20 to 26 F. should be used. 
Smaller ones are unsatisfactory and larger ones are un- 
necessarily painful. Any table of a convenient height 
will do for the purpose. The instruments and applica- 
tions should be convenient to the operator, so that it will 
not be necessary for him to drop the instrument until 
the examination is complete. It is advisable to conduct 
the examination in a darkened room, as a bright light 
diminishes the clearness of the field of vision. 

The endoscopic examination is conducted from behind 
forward, the tube being inserted as far as the membran- 
ous urethra, or, if desired, as far as the vesical orifice of 
the urethra. The insertion of a straight tube into a 
curved urethra frequently puzzles the beginner, but the 
necessary tact is easily acquired. The method of per- 
forming this little feat is as follows : The patient being 
in the recumbent position, the operator, standing to the 
left of the patient, introduces the endoscopic tube down 
to the bulbous urethra, care being taken to keep the 
distal extremity of the tube against the roof of the ure- 
thra at this point, while the ocular extremity is de- 
pressed toward the feet of the patient. Simultaneously 
with this movement the right hand, resting against the 
root of the penis, forcibly depresses the latter, which re- 
laxes the suspensory ligament and tends to straighten 
the urethral canal ; with this movement the endoscopic 



72 DISEASES OF THE URETHRA. 

tube should be steadily pressed onward, when it will be 
felt to slip through the isthmus and into the posterior 
urethra, where its further progress offers no difficulties. 
The difficulties the beginner usually meets with are from 
pressing the tube too far down into the bulbous urethra, 
where it is liable to pass beyond the isthmus, and from 
too forcible depression of the ocular extremity before it 
is passed into the posterior urethra. 

In this, as in all other urethral instrumentation, the 
utmost gentleness must be used, otherwise the results 
will be extremely unsatisfactory, as the reaction follow- 
ing an endoscopic examination may be so severe as to 
preclude its further use. 

It is rarely advisable to pass the instrument through 
the vesical orifice of the urethra as the annoyance of the 
escaping urine will be considerable. It should, how- 
ever, be passed deep enough to freely expose the caput 
gallinaginis. In some cases, where from the symptoms 
and the results of the examination of the urine we can 
positively exclude a pathological condition of the pos- 
terior urethra, it is not necessary to pass the tube be- 
yond the isthmus of the urethra. 

The endoscopic appearance of the urethra in health 
and in disease is somewhat difficult to describe. Such 
information is best conveyed by means of clinical demon- 
strations. There are, however, several fundamental prin- 
ciples governing the subject of urethral endoscopy which 
the beginner should bear in mind. 

If we expose the healthy urethra in the cadaver, by a 
longitudinal incision, we find that it is an exceedingly 
delicate, pale, glistening membrane, resembling the con- 
junctiva. Its surface is smooth and reflects the light 
throughout its whole extent. If we make traction on its 



URETHRAL ENDOSCOPY. 73 

cut edges, its lateral extensibility is seen to be consider- 
able, but varies in different portions of the urethra. 

During- life the same appearances are present, modi- 
fied, however, by the blood-vessels, which give to it a 
pink color, which varies in depth in different portions of 
the urethra, and is darker in the dark-skinned than in the 
fair. The same smoothness and glistening qualities per- 
tain to it in life as in death. Disease produces variations 
in the appearance of the urethra that are easily recog- 
nizable by endoscopic examination. These variations are 
dependent somewhat on the nature and duration of the 
disease. A recent acute inflammation of the urethra 
produces a marked hyperaemia and consequent increased 
redness of the mucous membrane, and the smooth, glisten- 
ing appearance will be dimmed or clouded by the des- 
quamation of the epithelium, and the bathing of its sur- 
face with pus, mucus, and epithelial debris. 

Patches of chronic inflammation present a variable 
appearance, dependent on the nature and duration of the 
inflammatory process. If in the posterior urethra, the 
mucous membrane presents a papillated, velvety appear- 
ance, and its glittering smoothness is lost. Patches of 
granulation tissue present the characteristic mulberry 
appearance, and occasionally trachoma may be observed. 
If the granulations are recent, they bleed with the slight- 
est touch ; if of long standing, cicatrization may have 
begun. In the latter case the granulation tissue may be 
streaked with paler areas which mark the sites of be- 
ginning cicatrization or stricture formation. Adjoining 
areas may be healthy, but are more often in a state of 
catarrhal inflammation, indicated by a cloudiness of the 
surface. Side by side may be seen patches of granu- 
lation tissue ; part in a florid vascular condition, part 



74 DISEASES OF THE URETHRA. 

less vascular undergoing cicatrization, with other patches 
of smooth, pale, gray tissue, that mark the completion of 
the process of cicatrization. In juxtaposition with the 
above there may be seen areas that are healthy or under- 
going a mild catarrhal inflammation. 

In chronic urethritis the orifice of the urethral glands 
may sometimes be seen as minute slightly elevated 
points, and the orifices of the lueume are often marked by 
minute epithelial erosions. The infection of these glands 
a ml lacunae is a prolific cause of the prolongation of a gon- 
orr7wea, and it has been observed that it is in the situation 
where they are most numerous that chronic lesions are found 
with the greatest frequency . I have noticed in a number of 
rases, when the endoscopic tube was withdrawn to that 
portion of the bulbous urethra which marks the site of 
the opening of the ducts of Cowper's glands, a drop of 
pus, and sometimes a little gush of thin, milky-looking 
fluid, would suddenly appear in the field. The inference 
to be drawn from this is, that not infrecpiently Cowper's 
glands are involved in the chronic inflammatory process 
and may be the source of many obstinate urethral dis- 
charges. 

In the withdrawal of the endoscope the retreating tube 
is closely followed by the collapsing urethral walls, which 
form the side of a cone or funnel ; the apex of the cone is 
called the central point of the endoscopic field and is the 
point of apposition of the urethral wall. As the urethra 
collapses around the extremity of the endoscopic tube, to 
become approximated at the central point, it is thrown 
into minute ridges, which are most marked at the cen- 
tre and disappear toward the periphery (Fig. 20). If the 
urethra is healthy and resilient these ridges are most 
minute, and may be imperceptible, although they can 



URETHRAL ENDOSCOPY. 75 

usually be detected. If the urethra, however, has lost its 
resiliency from any cause, such as oedema of its walls, 
chronic infiltration, or stricture formation, it will collapse 
less uniformly as the tube is withdrawn from the urethra, 
and will be thrown into larger folds, as in Fig. 21, which 






Fig. 20. Fig. 21. Fig. 22. 

represents the swollen urethra in an acutely inflamed 
condition, or in Fig. 22, where the urethra is rigid from 
stricture formation. The shape of this funnel is of con- 
siderable importance, as it indicates the degree of resil- 
iency of the urethra. If the urethra is rigid from chronic 
infiltration with sclerosis, it will collapse less readily, 
and the funnel formed on withdrawal of the tube will be 
longer than normal. If the infiltration is recent and soft, 
as in acute inflammation, the opposite condition is found 




S 




Fig. 23. — Diagram illustrating the shape of the Endoscopic Funnel. 

— the funnel will be very short and the urethral walls may 
even bulge into the endoscopic tube. 

In the healthy urethra the appearance of the funnel 
varies in different portions of the urethra (Fig. 23). It 
will be well for the beginner to familiarize himself with 
these normal variations, otherwise endoscopy will be very 
puzzling. At the vesical orifice the funnel is short, and 



76 DISEASES OF THE URETHRA. 

the apex occupies the centre of the field. As the tube 
is withdrawn the caput gallinaginis gradually comes into 
view, at first as a slight protuberance on the floor of 
the field, gradually increasing in size as the instrument is 
withdrawn, until, when fully exposed, it occupies two- 
thirds of the endoscopic field, the apex of the funnel, 
being convex, conforming to the contour of the caput 
gallinaginis. On further withdrawal of the tube the 
caput rapidly disappears and the apex resumes its central 
punctate form. This point marks the entrance into the 
membranous urethra, where the funnel is short and the 
puncta in the centre of the field. The bulbous urethra is 
next entered. Here is the field of the greatest muscular 
activity. The accelerator urinae squeezes the urethral 
walls forcibly against the end of the tube, and may even 
expel the endoscope if it is not firmly held. This may be 
obviated by tilting upward the ocular extremity of the 
instrument. At this point the muscular activity of the 
urethra forces the mucous membrane into the tube so 
that the funnel practically disappears. The withdrawal 
of the instrument into the pendulous urethra is marked 
by the cessation of muscular activity, and the prolonga- 
tion of the funnel. At the fossa navicularis the funnel is 
longest and the canal not wholly obliterated at the apex, 
where the central figure may be very large and irregular 
in form. 

If, during endoscopic examination, the tube is rapidly 
withdrawn from the urethra, the funnel will be longer 
than if the instrument is withdrawn slowly. It is well, 
therefore, to accustom one's self to withdraw the instru- 
ment at a uniform speed. 

To recapitulate : Urethral endoscopy can only be 
properly taught in the clinic room, and the beginner 



URETHRAL ENDOSCOPY. 77 

should first familiarize himself with the endoscopic 
appearance of the healthy urethra, and then study the 
changes produced in the urethra by disease. The impor- 
tant points to note are the color, degree of smoothness, 
and lustre of the urethra ; the character and amount of 
secretion on its surface ; its resiliency as indicated by 
the shape of the cone and central figure, and the more 
or less alteration of the ridges of its surface. 



CHAPTEE IX. 



URETHRAL MENSURATION. 



For the purpose of measuring- the interior of the iire- 
thra, with special reference to abnormal points of con- 
traction, we may have recourse to a number 
of instruments. A few of these will, how- 
ever, suffice. Among - the number we may- 
mention the steel sound, the bulbous bou- 
gie, and the urethrometer. 

The steel sound (Fig. 24) is of value in de- 
termining the calibre of the urethra at its 
narrowest point. If it is passed into the 
urethra and is neither resisted on its en- 
trance nor held on its withdrawal — slips in 
and out unobstructed — we may safely say 
that the calibre of the urethra at its nar- 
rowest i>oint is at least equal to the size 
of the sound. For many purposes this is 
all that is required ; and on the results of 
this examination we may frequently assure 
our patient that we can exclude stricture of 
the urethra from being one of the patho- 
logical conditions from which he is suffer- 
ing. If the sound, after passing freely for 
a certain distance, butts up against an ob- 
Fig. 24. —The struction which it will not readily penetrate, 
Sound! or ^ ** P ene trates the obstruction and is 



URETHRAL MENSURATION. 79 

held by the latter on its withdrawal, we may justly con- 
clude that a stricture exists at the point of obstruction. 

While the sound is the least irritating- of all the ure- 
thral instruments that are used for measuring- the ure- 
thra, its application is limited. It is of more negative 
than positive value. By this is meant that while with 
the sound we may in many cases exclude a stricture ; yet 
where a stricture is present it is often difficult of deter- 
mination and exact localization by the sound ; and the 
latter is valueless in measuring the urethra posterior to 
the point of stricture. 

The bulbous bougies, which should be flexible (Fig. 
25), are of more value in determining the exact location of 




The Bulbous Bougie. 



a stricture, but are open to the objection of the sounds 
that they are unsuited for the measurement of the ure- 
thra where an anterior stricture is present, and they are 
also very liable to be held, on withdrawal, by normal ure- 
thral folds, and give a sensation as if a stricture was pres- 
ent where none really exists. 

It frequently happens that the meatus may be so nar- 
row as to preclude the use of either bougies or sounds of 
sufficient calibre to measure the urethra. To overcome 
these objections the urethrometer has been devised. It 
is introduced closed, and can be opened or dilated within 
the urethra to any desired extent. The urethrometer 
in common use is the one devised by Otis (Fig. 26). 
The cut of this instrument explains its mechanism so 
well that it is unnecessary to waste words on either its 
description or use. 



80 



DISEASES OF THE URETHRA. 




As the accuracy of the results obtained by 
this urethrometer depends on the skill of the 
operator and the sensibility of the patient — 
two very variable factors — the results ob- 
tained are often unreliable. In order to 
eliminate these two uncertain factors I have 
devised an urethrometer (Fig-. 27) on a differ- 
ent principle. This instrument is introduced 
within the urethra to the de- 
sired distance, when a spring- 
is released which expands the 
measuring- arms. The latter 
maintain a uniform pressure 

I against the urethra, regard- 

less of whether they are pass- 
ing through a dilated or a 
contracted portion. The op- 
erator has, therefore, simply 
to introduce the instrument, 
release the spring, and follow 
the reading of the index as it 
is withdrawn. This instru- 
ment has proven perfectly sat- 
isfactory from a mechanical 
point of view, but it is open 
to the objection, in common 
with the other urethrometers, 
that it is more irritating and 
painful than the sound. 
The physician who understands the nat- 
ure, and is not disposed to magnify the 
evils, of stricture of large calibre, will rare- 
ly find it necessary to bring into requisi- 



Fig. 26. — The 
Otis Ure- 
thrometer. 




Fig. 27. —The 
Author's Ure- 
thrometer. 



URETHRAL MENSURATION. 81 

tion either the bulbous bougies or the urethronieter, and 
as his experience increases the greater will become his re- 
liance on the steel sound, and the less will he depend on 
the use of more complicated instruments in the estima- 
tion of the calibre of the urethra and in the diagnosis of 
urethral stricture. 



CHAPTEE X. 
CHEONIC ANTEEIOE UEETHEITIS. 
Treatment. 

Of all the diseases that the genito-urinary surgeon is 
called upon to treat, there is none that he meets more 
frequently, none that is so obstinate in yielding to the 
ordinary remedies, and none that is more harassing to 
the physician and patient than chronic urethritis. 

Before falling into the hands of the specialist the 
patient has probably made the usual rounds, from one 
physician to another, and has been buffeted from pillar to 
post until he despairs of a cure. In the meantime the 
disease has, in his imagination, assumed a magnitude pro- 
portionate to its persistency. Before the pathology of the 
disease was properly understood, and before endoscopic 
examination and treatment were employed, the annoyance 
caused by this disease fully justified Bicord's celebrated 
definition of hell as a place where patients were contin- 
ually clamoring to be cured of their gleet. 

At the present time, however, under modern methods 
of treatment, chronic urethritis has become much more 
tractable, and the results are often highly satisfactory. 

If a patient applies for treatment during one of the 
exacerbations of his chronic urethritis, we should not 
forget that for the time being we have an acute inflamma- 
tion to deal with, requiring the hygienic precautions and 



CHRONIC ANTERIOR URETHRITIS. 83 

the remedies that are efficacious in the treatment of acute 
urethritis. In these cases- the temptation is great to 
yield to the importunities of the patient, to adopt heroic 
methods of treatment, either by powerful injections or 
by the use of instruments. It is a cardinal rule, however, 
never to introduce an instrument within the urethra 
when it is actually inflamed. To. this rule there is only 
one exception, and that is when it is necessary to intro- 
duce an instrument for the relief of a greater evil, such 
as retention of urine. 

Granted that the exacerbation has subsided, and that 
the patient complains of but little but the gleety dis- 
charge, the question comes up, what line of treatment 
should we pursue ? The patient will probably volunteer 
the information that he has tried the various internal 
remedies and injections in common use, with the uniform 
result, that while the exacerbations yield to treatment 
the inflammatory disturbance is only ameliorated and 
not cured, as proof of which he refers you to the gleety 
discharge, of which he is unable to rid himself. 

Unquestionably the only rational treatment to pursue 
in such cases is the local treatment of the inflamed areas, 
undertaken with the view of restoring the urethra to 
a healthy condition. It is not to be understood by 
this that treatment of a general character is to be 
ignored. On the contrary, it is important that such 
measures shall be pursued as will tend to soothe the 
inflamed urethra ; excessive acidity of the urine should 
be counteracted, stimulating drinks and sexual excesses 
should be rigorously tabooed. 

Having decided on local treatment the first thing to be 
done is to pass a steel sound along the urethra. A 
volume might be written on this subject alone ; in fact, 



84 DISEASES OF THE URETHRA. 

it is a difficult task to do it justice within a limited 
space. I have stated that a steel sound should be 
passed, while fully conscious that no less an authority 
than Sir Henry Thompson, in his recent work on " Dis- 
eases of the Urinary Organs," gives the preference to 
flexible instruments. He says : " No patient will will- 
ingly allow another surgeon to pass for him a solid 
instrument, if you have passed for him a flexible one as 
easily as you may readily do. The latter gives so much 
less pain than any other, and produces so much less 
irritation." With all due respect for the authority 
quoted, I contend that the solid instrument, properly 
manipulated, is the least irritating to the urethra, and 
the easiest for the patient to bear. It is true that where 
the urethral canal is tortuous, as is frequently encoun- 
tered where there is an enlarged prostate, a flexible 
instrument will pass with the greatest ease and the least 
damage to the urethra, but this condition is foreign to 
the subject under discussion. 

Instruments under No. 18 of the French scale should 
be flexible, as solid instruments under that size are liable 
to damage the urethra, even if carefully handled. If 
the operator is a novice in the art, or if stupidity and 
ignorance combined, prevent him from recognizing the 
necessity of delicate manipulation, then by all means 
should he use a flexible instrument, and thus reduce to 
a minimum his capability of damaging the urethra. It is 
not saying too much to assert that the fate of the genito- 
urinary surgeon depends on the deftness with which he 
passes a steel sound. If he is awkward and rough in 
the passage of this instrument he will never be success- 
ful, no matter how much learning he may bring to bear 
on the subject. A patient never forgives rough treat- 



CHRONIC ANTERIOR URETHRITIS. 85 

ment with his urethra, once it has been shown him with 
what ease the sound will pass if properly used. 

In passing a sound on a patient for the first time select 
one that is large enough to comfortably fill his urethra. 
Do not make the mistake of selecting one too small, for 
this will only increase the difficulties. Warm the sound 
to the temperature of the body, and oil it well. Assure 
the patient that you will deal gently with him. It is use- 
less to try to direct his attention from what you are do- 
ing, for he looks on the operation as too serious to per- 
mit his attention to be distracted from it by any artifice. 
The patient being in the recumbent position/the oper- 
ator standing at his left side, inserts the tip of the in- 
strument within the urethra, its axis corresponding with 
that of the latter ; the butt end of the instrument should 
be lightly grasped by the thumb and forefinger of the 
right hand, while the same fingers of the left hand should 
grasp the glans penis, keeping traction on it, which pre- 
vents the sound from catching on the folds of the ure- 
thral mucous membrane (Fig. 28). As the sound ad- 
vances the butt end is gradually tilted upward so as to 
keep the axis of the instrument and the urethral canal in 
line. When the tip of the instrument has reached the 
subpubic curvature, the right hand ceases to guide or 
support the instrument, which is now permitted to pur- 
sue its own course within the urethra, its propelling force 
being its own gravity, its guiding agent being the ure- 
thra itself. At this stage the passage of the sound may 
be materially assisted by pressing with the free right 
hand on the pubic junction of the penis, which relaxes 
the suspensory ligament and tends to straighten the ure- 
thral canal. At the same time the free fingers of the left 
hand should press against the urethra at the subpubic 




Fio. 28.— Passage of Sound (First Stage). 




Fig. 29.— Passage of Sound (Second Stage). 



CHRONIC ANTERIOR URETHRITIS. 87 

curvature, while the penis is swept away from the body 
and toward the feet of the patient ; the extent of this mo- 
tion being- guided by the sensations imparted by the in- 
strument (Fig. 29). If this manoeuvre is properly exe- 
cuted the sound will pass without a hitch, and almost 
painlessly, into the bladder. 

There is nothing more exasperating than to witness an 
unskilful operator introduce a sound. He grasps the 
instrument and handles it as if he had to make a canal, 
rather than to follow one. He has well-defined anatomi- 
cal ideas as to the course the urethra should pursue, and 
to his ideas the urethra must conform, regardless of its 
detriment in doing so. 

If it were only realized with what exquisite sensibility 
the urethra is endowed, and of what delicate structures 
it is composed, surely there would be more forbearance 
shown, and more gentleness and patience exercised in its 
instrumental treatment. Unfortunately the combination 
of ignorance and unskilfulness oft go hand in hand, and 
nowhere is more potent for evil than in the urethra. 

A great stumbling block to the unskilful manipulator 
of urethral instruments is the membranous portion of the 
urethra where it passes through the triangular ligament 
and is grasped by the compressor urethrse (Fig. 3), and 
here we meet that which is often but a cloak to cover the 
awkwardness of the operator, and is the bugaboo of the 
novice, namely, spasmodic stricture. While a spasm of 
the external sphincter muscle (compressor urethrae and 
external prostatic sphincter) is not infrequently met 
with, especially in nervous subjects who are undergoing 
their first examination, no amount of spasm will prevent 
the passage of a steel sound if it is properly manipu- 
lated. Where there is a failure to pass a sound through 



88 DISEASES OF THE URETHRA. 

the urethra, it can only indicate either unskilful manipu- 
lation, organic stricture, or a tortuous urethra from prostatic 
enlargement. 

The objects to be attained by the passage of the sound 
are both diagnostic and therapeutic. As the sound is 
passed, its contact with the diseased and tender areas will 
give rise to painful sensations, by which means the oper- 
ator becomes cognizant of their situation. It should be 
remembered, however, that certain situations in the ure- 
thra are more sensitive than others ; as the sound passes 
over the caput gallinaginis a sickening sensation is often 
experienced, and in long-standing inflammatory affec- 
tions of this part, especially if associated with deep 
structural changes, this sensation may be heightened to 
a degree that is distressing. The healthy pendulous 
urethra is more sensitive than the bulbous urethra, but 
this seems to be owing to the fact that it yields less 
readily to the passage of the sound. I have noticed, 
however, in many urethrae which have suffered from a 
gonorrhoea, that at a point about an inch and a half 
from the meatus the urethra is very sensitive, although 
no lesion could be discovered in this situation to account 
for it. 

The gentle passage of the sound never causes hemorrhage 
in the healthy urethra, and when such does occur it indicates 
either unskilful use of the sounds or a pathological condition 
of the urethra. 

The therapeutic or remedial effects of the passage of 
the sound may be classified as follows : 

1. The allaying of urethral hyperesthesia. 

2. The restoration of the urethral canal to its normal 
calibre, and the absorption of inflammatory products. 

3. By expressing the contents of the suppurating ure- 



CHRONIC ANTERIOR URETHRITIS. 89 

tliral glands and lacuna?, it exerts a curative influence 
on the pyogenic process. 

When a sound which comfortably fills the urethra has 
been passed, a second sound, even larger than the first, 
may be passed without eliciting as much pain. The first 
sound, by its pressure on the terminal filaments of the 
nerves, has an obtunding or anaesthetic effect on the ure- 
thra ; for this reason it is advisable that a sound be 
passed previous to the introduction of other urethral 
instruments. In the dilatation of strictures much suffer- 
ing may be avoided if the sensibility of the urethra is 
obtunded by the preliminary passage of a sound which 
only exerts a gentle pressure on the urethra. A patient 
who has had an acute urethritis will often, after the dis- 
charge has ceased, complain of teasing rmins in the ure- 
thra, and an indefinable feeling that it is not altogether 
in a healthy condition. If the sound is gently passed in 
his urethra, he will at once express the feeling of relief 
and comfort he has obtained. In the course of two or 
three days this hypemesthetic condition returns, but with 
diminished intensity, and will entirely disappear on the 
repetition, for a few times, of the passage of the sound. 

To understand the second therapeutic object for which 
the sound is used a brief resume of the condition in 
which the urethra is usually found in chronic urethritis 
will be necessary. The mucous membrane at the in- 
flamed areas is thickened from increased proliferation of 
the epithelial cells, and infiltration of the mucous and 
submucous tissues, with leucocytes, which, where granu- 
lar urethritis exists, show a marked tendency to connec- 
tive-tissue formation and cicatricial contraction. 

Mr. Berkeley Hill, in his work on chronic urethritis, 
says : " If the induration has invaded a long tract of the 



90 DISEASES OF THE URETHRA. 

canal, over such tracts the mucous membrane is irregular 
in contraction and grayish in hue, or there may be alter- 
nating red patches of chronic inflammation and gray 
patches of contraction. These varieties follow each other 
in quick succession, so that in the same urethra there 
may be, perhaps, a dozen different patches, some old, 
gray, and shrunken ; some dull red, but unyielding; some 
covered by granulations ; in some where the infiltration 
has not taken place, or has been absorbed, the tissue is 
again yielding and resilient." Such a urethra as is pict- 
ured above has lost much of its resiliency, and in certain 
portions well-defined contractions may be detected with 
the urethrometer. In these cases, if the sounds are 
passed every third or fourth day, each successive sound 
being slightly increased in size, the inflammatory exu- 
dates will slowly disappear, the patient will often ob- 
serve that his urethra is becoming softer, or, as he ex- 
presses it, it feels more natural, and the dribbling of 
urine, so often complained of as taking place a few mo- 
ments after urinating, will cease to annoy him. This 
dribbling is caused by the rigid urethra, which does not 
collapse immediately after urinating, and consequently 
the emptying of the canal is only accomplished when 
the muscular and elastic tissue of the urethra is able to 
overcome its rigidity. 

The manner in which the periurethral exudates under- 
go absorption as a result of the systematic passage of 
the sound is not easy of explanation, but it is probably 
due to the slight reactionary inflammation producing de- 
generative changes which facilitate their absorption ; the 
latter being aided by the process, allied to massage, 
which the sounds exercise against the urethral walls. 

There is no evidence to prove that exudates which 



CHRONIC ANTERIOR URETHRITIS. 91 

liave undergone true connective-tissue formation eve 
undergo absorption or removal bj- any method of treat- 
ment short of actual destruction of the tissue, though the 
passage of the sounds may produce a rearrangement of 
the connective-tissue cells, and thus increase, by stretch- 
ing and thinning of the stricture, the lumen of the ure- 
thra at the constricted point. 

In connection with the subject of the passage of 
sounds there arise the pertinent queries : What is the 
normal calibre of the urethra, and To what size should 
the urethra be dilated ? 

These are difficult questions to answer, since no defi- 
nite measurement or rule can be given. The law formu- 
lated by Otis, that the calibre of the urethra bears a 
definite relationship to the circumference of the penis, 
has been, I unhesitatingly state, productive of incalcula- 
ble mischief ; and in conjunction with another law, laid 
down by the same authority, namely, that stricture is the 
progenitor of gleet, has done more to injure urethral 
surgery in this country than anything I can think of. 
In the public clinics of our colleges it is not uncommon 
to see a patient with a chronic urethritis subjected to 
the following line of treatment : 

The circumference of his penis is taken, which, by the 
way, is a very variable quantity, even in the same ure- 
thra. From this measurement the calibre of the urethra 
is estimated, and the statement boldly made that the pa- 
tient's urethra should permit of the passage of a certain- 
sized sound, usually much too large. The next step is to 
compel the unfortunate urethra to swallow the sound, 
whose dimensions has been obtained from the circumfer- 
ence of the penis, and woe betide the patient if Nature 
has not provided him with a capacious urethra. His 



92 DISEASES OF THE URETHRA. 

meatus is slashed with a boldness that would compel ad- 
miration were it in a better cause. His urethra is ex- 
plored for strictures, and in such hands a stricture can 
always be discovered, the slightest coarctation in the di- 
lated urethra is pounced upon, as if it were a deadly 
enemy, and subjected to the most ruthless and often un- 
necessary treatment. 

There is no more justification for saying - that the size 
of the urethra bears a definite relationship to the size of 
the penis than there would be to say that the size of the 
(esophagus bears a definite relationship to the size of the 
neck. Unfortunately for the urethra it is a patient canal 
and will often submit to extreme dilatation, so that sounds 
of very large size can be forcibly passed ; but while this 
proves the great dilatability of the urethra, it is far from 
proving that the size of the urethra is equivalent to the 
largest sound that can be made to pass. 

While no definite rule can be laid down concerning the 
calibre of the urethra, we must necessarily have some 
idea of its size in a given case. This is, however, a matter 
which must depend on the judgment of the surgeon. In my 
own practice, if Ican])ass a No. 26 French sound, without 
its being obstructed in its passage or held on its withdrawal, 
f Jmre no hesitation in assuring the patient that be has no 
stricture. Even if in such a urethra I detect poi)its of nar- 
rowing with the urethrometer, which may be classified as 
strictures of large calibre, I make ?ny assurance none the less 
positive, as I cannot recognize a stricture which readily per- 
mits the passage of a No. 26 French sound, as being of itself 
the cause of any urethral disease, or requiring treatment. It 
is true that I may introduce, in the treatment of the ure- 
thra, instruments of a larger size, but that is done for the 
pressure effects on the urethra, the dilatation of existing 



CHRONIC ANTERIOR URETHRITIS. 93 

strictures of large calibre being- a secondary considera- 
tion. I rarely, however, introduce a sound of a larger size 
than No. 32 French, and seldom permit the instrument to 
remain longer in situ than a minute — its retention for a 
longer period being not only too painful, but it is fol- 
lowed by too much inflammatory reaction. 

The passage of the sounds has a beneficial effect on the 
pyogenic process, which is such an obstinate feature of 
chronic urethritis. 

It has already been shown how a gonorrhoea is often 
prolonged by its localization in the urethral follicles and 
glands, in which situation it is but little amenable to the 
action of injections ; if a sound is passed in such a urethra, 
its withdrawal is followed by a drop of pus which was pre- 
viously invisible. In order to differentiate between the 
pus on the free surface of the urethra and the pus that 
is lodged in the urethral crypts, it is only necessary to 
have the patient urinate immediately before passing the 
sounds. By this means the pus on the free surface of the 
urethra will be washed out with the urine. If a drop of 
pus now appears immediately after the passage of the 
sounds, the inference is obvious that it is the aggregate 
of the contributions made by the urethral follicles and 
glands at the time their orifices were dilated and their 
walls squeezed by the passage 
of the sound. The emptying 
of these suppurating crypts can- 
not but have a beneficial effect, 

• n •» • iii e Fig. 30. — Diagram Illustrating 

especially if, as is probably of- the Action * f the Sounds £ 

ten the Case, their ducts had Expressing the Contents of 

, , , , , _,. the Urethral Crypts. 

previously been occluded. Fig. 

30 illustrates this action of the sounds on the urethral 

crypts. A careful observation of this point will demon- 





94 DISEASES OF THE URETHRA. 

strate the great frequency with which chronic urethral 
discharges are localized, in whole or in part, to the ure- 
thral glands and lacuna?, and it is probably more from the 
emptying these crypts than from any other cause that the 
passage of the sounds is so efficacious in the treatment 
of gleet. 

It not infrequently happens that the meatus, which is 
one of the physiological points of narrowing, prevents 
the passage of sounds sufficiently large for the dilata- 
tion of the urethra to the desired extent. If a contract- 
ed meatus offers an impediment to the treatment of the 
urethra, the inflexible rule is that it should be unhesi- 
tatingly cut. Its incision is simple, safe, and satisfactory, 
while attempts at dilatation or divulsion are as brutal as 
they are useless, and should receive the strongest con- 
demnation of the profession. The meatus should only be 
cut to a size which will readily permit the passage of an 
instrument of the size to which we wish to dilate the 
urethra. Cutting beyond this size is unnecessary, inju- 
rious, and unjustifiable. I protest against the reckless 
laying open of the glans penis down through the froenum, 
which one sees so often, as the result of treatment in the 
hands of some specialists, whose claim to the title seems 
to rest on their special eagerness to use the knife, and 
special ignorance of its proper use. 

A recent writer on stricture (Lydston) g-oes so far as to 
say that he "practised with advantage" stitching of the 
edges of the quasi-mucous covering of the glands and 
the mucous lining of the urethra together for the pur- 
pose of insuring the patency of the meatus, and follows 
this up by saying : " In some cases the fra?num pmeputii 
is attached so far forward that a proper meatotomy can- 
not be performed. In such cases the frrenum should be 




Fig. 31. 



CHRONIC ANTERIOR URETHRITIS. 95 

cut away in such a manner as to leave a clear field for 
the incision of the meatus." 

As an illustration of how far this overdoing of surgery 
may be carried, I ap- 
pend, .a sketch of a 
case (Fig 1 . 31) which 
was recently under my 
care, and had been mu- 
tilated as shown by a 
disciple of Otis. This 
is overdoing surgery 
with a vengeance, yet 
it is but a fair representation of a kind of genito-urinary 
surgery that is unfortunately so prevalent in this country. 

A patient with such a meatus loses the fossa navicu- 
lars, which Nature has provided as a recepticle for the 
normal urethral secretions. As a result his meatus is al- 
ways moist. He is prone to expose his urethra by separ- 
ating the flaps of the glans penis, in order to observe the 
normal urethral secretion, to which he attaches patholog- 
ical importance. Coupled with this he will note that his 
stream has lost much of its force, and spreads as if it 
came from a watering-pot. A patient in such a condition 
is liable to become hipped on the subject, and is often in 
a most unenviable condition of mind over a pathological 
state of his urethra, which exists only in his own disor- 
dered imagination. But the blame for this unenviable 
condition rests, nevertheless, on the shoulders of the 
man who was overzealous in cutting his meatus. It is a 
fortunate thing that urethral surgeons, from the nature 
of the work, are practically exempt from malpractice 
suits, otherwise this would be a prolific field for such 
cases. 



96 DISEASES OF THE URETIIKA. 

It sometimes happens that it is difficult or impossible 
to dilate the urethra with sounds to the required extent, 
owing- either to the tenderness of the urethra or the un- 
yielding- nature of the urethral callosities. In this case, 
if further dilatation is absolutely necessary in order to 
effect a cure, we may have recourse to dilating urethrot- 
omy. 

Professor Otis, who, though not the originator of the 
method, was the first American surgeon to place dilating 
urethrotomy — by his writings, his instruments, and his 
results— in an impregnable position, and his name will 
ever be closely entwined with the history of this oper- 
ation. It is a pity that the lustre of the name and the 




Fig. o2.— The Otis Dilating Urethrotome 

brilliancy of the operation should be dimmed by the 
abuse of this method of treating strictures, which has 
followed the undue estimation of the importance of strict- 
ure of large calibre, and the value of dilating urethrot- 
omy as a means of its cure. The best instrument we can 
use for this purpose is the Otis dilating urethrotome 
(Fig. 32), which is based on the correct principle that 
the stricture tissue should be placed on the stretch at the 
moment of its incision. Before using the instrument the 
location of the stricture and the size of the healthy ure- 
thra should be ascertained by means of the urethrome- 
tre. The urethrotome should be inserted to such a 
depth that when the knife is raised from its socket it will 
begin cutting at the deep or posterior aspect of the strict- 



CHRONIC ANTERIOR URETHRITIS. 97 

lire. The dilating blades of the instrument should be sep- 
arated until the stricture tissue is put on the stretch, when 
the knife should be drawn through it from behind for- 
ward, and then thrust back into its socket again. If the 
first incision does not permit of the proper dilatation 
of the urethra, the dilating blades should be separated 
still further and the incision repeated. Otis places much 
importance, from a curative point of view, in completely- 
dividing the stricture. 

When we consider that in its longitudinal direction the 
urethra is a variable quantity ; that a slight difference 
in the traction made on it may make a very perceptible 
difference on the location of the stricture ; that this error 
may be magnified in inserting the urethrotome ; that the 
urethrotome most commonly used (the Otis) alters its po- 
sition in the urethra during the process of being dilated — 
we will readily see that the exact localization of the knife 
at the point of stricture is matter of considerable diffi- 
culty and uncertainty. 

In practice it is necessary, in order to be certain of cut- 
ting the whole length of the stricture, to make the incision 
longer than the stricture, and herein lies the greatest 
danger of urethrotomy, the cutting of the healthy urethra, 
which is not only more vascular, but its walls are also 
thinner than at the strictured portion, and its incision is 
consequently more liable to be followed by dangerous 
hemorrhage and extravasation of urine. 

The incision should always be made on the roof of the 
urethra, for in this situation extravasation is least liable 
to occur. After the operation of internal urethrotomy 
urethral dilatation should be maintained by the passage 
of sounds until the incision has healed. 

As this operation lays open tissues capable of absorb- 



98 DISEASES OF THE URETHRA. 

ing septic material, the instruments should be above 
suspicion, and the urethra uncontaminated as far as dili- 
gent antiseptic irrigation will render and maintain it. If 
the urine is healthy it is non-irritating and may be disre- 
garded, provided extravasation does not take place. If 
extravasation of the urine occurs, it is very liable to 
undergo decomposition, which converts it from a harm- 
less to a most irritating and destructive agent, capable of 
blighting whatever it comes in contact with. If the urine 
has already undergone decomposition within the bladder, 
antiseptic treatment should be adopted, to purge from 
that viscus the bacterial ferments which render the urine 
so noxious, before urethrotomy should be attempted. 

A few words may be said about the curative effect of 
urethrotomy on stricture. It has been often asserted 
that if a stricture is completely severed absorption of the 
sundered cicatricial tissue will follow, and by this process 
of absorption a permanent cure will ensue. My personal 
experience does not warrant me in holding this opinion. 
I can readily understand how the inflammatory infiltra- 
tion in a recently inflamed urethra may, if the exudates 
have not undergone organization, become absorbed and 
the urethra be restored to its normal calibre. I ca:i un- 
derstand how a stricture which has ceased to contract 
may, after it is cut, show but little tendency to recontrac- 
tion, as there would only be contraction from the splice 
of new material that occupied the gap formed by the 
incision. I can understand how a contracting stricture 
may be cured by dilatation and keeping it dilated until 
it has ceased to contract, for even the contraction of cica- 
tricial tissue has an end. I can readily understand all 
this, but why a simple incision will cause the absorption 
of cicatricial tissue is beyond my comprehension, and if 



CHRONIC ANTERIOR URETHRITIS. . 99 

it will do so in the urethra why will it not do so in other 
situations ? It seems irrational to me, and contrary to 
the laws of pathology, which, I fear, have been too much 
ignored by many urethral surgeons. 

The failures of urethrotomy to cure strictures are too 
numerous to be ignored, and the explanation that " with- 
out complete and absolute sundering of the stricture 
to its ultimate fibre recontraction sooner or later is cer- 
tain " (Otis, " Stricture of the Male Urethra," page 233), 
is too unreasonable to be even considered as a loophole 
of escape out of an embarrassing dilemma. 

Aside from the failure of urethrotomy to cure stricture 
there are other objections too serious to be ignored. 

Chordee is a frequent sequence of urethrotomy. In 
many cases this is but temporary, but in a respectable 
minority the condition is a permanent one. If we exam- 
ine a urethra that has been cut we will see a longitudinal 
splice of cicatricial tissue that is pale and almost blood- 
less. If the cicatricial tissue extends deep enough to 
penetrate the cavernous tissue, chordee will ensue be- 
cause this tissue bears no resemblance to erectile tissue, 
and is incapable of extension during erection. A bend- 
ing downward of the penis at the point of stricture, fre- 
quently accompanied by dragging pains, will therefore 
be the unpleasant accompaniment of an erection, and in 
severe cases may render the patient impotent. 

The failure of urethrotomy to cure stricture, and its 
liability to be followed by chordee, are but trivial objec- 
tions when compared with the risk attendant upon the 
operation itself. It has been asserted that this opera- 
tion has no mortality, but this is a false assertion, and 
those that have often asserted it the loudest have been 
aware of its falsity. 



100 DISEASES OF THE URETHRA. 

The following-, on this subject, is quoted verbatim from 
J. William White's article on " Stricture of the Urethra," 
in Morrow's " System of Genito-urinary Diseases," vol. i., 
page 298 : 

" It must be remembered that no special advantage is 
claimed for this operation unless it is extensive, the fig- 
ures of Otis being usually adopted by the few practition- 
ers who habitually employ urethrotomy in stricture of 
large calibre in which no contra-indication exists to the 
method of dilatation above described. As to the mortal- 
ity, Watson's figures (collected by an advocate of this 
operation) (Boston Medical and SurgicalJournal, Decem- 
ber 29, 1887) show fifty-one deaths in twenty-five hundred 
and forty cases, or two per cent. ; but they include the 
statistics of all the extremists, whose operations were 
often on physiological narrowings, and therefore in pa- 
tients with sound urinary tracts. There is not a more 
able or more skilful genito-urinary surgeon in Europe 
than Guy on, and his experience is enormous, but we find 
that he had twenty deaths in four hundred and fifty -nine 
operations, or about 4.1 per cent. Stein places the mor- 
tality of internal urethrotomy of the penile urethra at 
from two to five per cent. (' Trans, of the American As- 
sociation of Genito-urinary Surgeons, 1889 '). Thomp- 
son had six deaths in four hundred and thirty operations. 

" A review of a large number of reported cases, and 
familiarity with a considerable number even less favora- 
ble and not reported, lead me to believe that these fig- 
ures rather underestimate the mortality, and that the 
practitioner who decides to cut a stricture anterior to the 
bulbo -membranous junction must do so with the full 
knowledge that there are at the least two chances in the 
hundred of losing his patient. 

" There should certainly be definite and well-grounded 
reasons for accepting this risk, and the operation which 
involves it should show results unmistakably superior to 
those of gradual dilatation — a procedure with practically 
no mortality at all." 



CHRONIC ANTERIOR URETHRITIS. 101 

The conservative surgeon who takes a rational view of 
the pathology of chronic urethritis will rarely find it 
necessary to tell his patient that in order to be cured of 
this malady he must submit to an operation that kills 
once in fifty times. 

I protest against the teaching that the existence or 
continuance of a gleet is dependent upon the presence of 
a stricture. I protest against the teaching that every 
irregularity in the urethra is a stricture, and in the 
presence of a gleet should be removed. I protest, most 
of all, against the reckless urethrotomies that are being 
done, every day, for the removal of irregularities in the 
dilated urethra that are in themselves harmless. 

Much of this work is done by incompetent men ; men 
who are specialists in its narrowest form ; men who will 
fearlessly mutilate a canal where they cannot see the 
havoc they are doing', and yet would shrink from the 
responsibilities of a herniotomy or tracheotomy. Truly 
" fools rush in where angels fear to tread." 

In a recent work on " Stricture of the Urethra " there 
appears the following : " I presume that there are many 
skilful men who would claim that a patient who takes a 
thirty to thirty-five French sound has no stricture. Yet 
a patient may take a forty French sound and the case still 
demand urethrotomy -." The writer who penned this must 
either be ignorant of the risks of the operation he recom- 
mends, or else wilfully oblivious to the safety and welfare 
of his patients. Yet this is but a sample among many of 
the length to which extremists are often carried by their 
peculiar views on stricture, and were it not that I feel 
keenly not only the prevalence, but also the danger of 
this teaching, this work would never have been written. 

I feel that an explanation is due the reader in appar- 



102 DISEASES OF THE URETHRA. 

ently permitting- the subject of the treatment of chronic 
urethritis to lapse from view, in order to condemn indis- 
criminate urethrotomy, but I may defend my course by 
stating- that it is in the treatment of chronic urethritis 
that so many needless urethrotomies are done for the 
cure of imaginary strictures, to which a pathogenic 
importance is attached, and it is for this reason that I 
have gone into the subject of urethrotomy in this chap- 
ter, instead of reserving it for consideration in the 
chapter on the treatment of stricture. "We must not, 
however, commit the error of relying exclusively on the 
use of the sounds, or gradual dilatation as a means of 
treating chronic urethritis. The method which will give 
the best results in the majority of cases is one which 
combines the gentle passage of the sounds, together with 
the application to the inflamed areas of astringent or 
slightly caustic remedies. The number of remedies that 
have been used in the treatment of this malady are 
legion, and as even an attempt to discuss them would be 
almost interminable, as well as most unprofitable, I pre- 
fer to give, instead, a resume of the method of treatment 
which I find in my own practice to give the best results. 

We will take, for the purpose of illustration, a patient 
who has a long-standing chronic urethritis which has 
gone through the usual routine of treatment by injec- 
tions, by sounds, and by internal medication, with the 
result that he is sometimes better and sometimes worse, 
but never entirely well. We will also suppose that he 
applies for treatment during one of the exacerbations of 
his urethritis. At this stage or during the exacerbation, 
it would be highly injudicious to make an instrumental 
exploration of his urethra. The patient will probably, 
in his anxiety to get well, insist that this be done, but 



CHRONIC ANTERIOR URETHRITIS. 103 

his importunities should not be yielded to, for doing 
so would simply aggravate the existing exacerbation 
without deriving any commensurate benefit from a diag- 
nostic or therapeutic point of view. The history of the 
case should be obtained and an examination of the urine 
made, to determine whether the disease is limited to 
the anterior urethra, or is complicated by a posterior 
urethritis. If the inflammatory disturbance is intense 
and urination painful, some of the balsamic mixtures are 
prescribed (page 32), or a simple alkaline mixture may be 
given, if the patient, who is by this time an authority on 
the subject, volunteers the information that he stands the 
balsams badly. If the exacerbation is a mild one we 
may content ourselves by telling the patient to drink 
freely of water ; plain water serves the purpose very well, 
but the alkaline mineral waters are to be preferred, such 
as the Bethesda or the Yichy. An injection like the fol- 
lowing should be prescribed : 

R . Ziaci sulphatis gr. xv. 

Plumbi acetatis gr. xxx. 

Aquae rosse f § vj. 

Tiucturge catechu, 

Tinctura? opii aa f 3 j. 

This should be used three or four times a day and 
gradually diminished in frequency as the discharge les- 
sens, until it is only used at bedtime, or discontinued 
altogether, as may be considered advisable. It is not a 
good plan to continue the same injection for a prolonged 
period as the urethra seems to become habituated to it, 
and a change is necessary. The method of performing 
the injection has already been described in the chapter 
on the treatment of acute urethritis, and need not be 
dwelt upon at the present time. In a few days the exa- 
cerbation will have subsided. This will be indicated by 



104 DISEASES OF THE URETHRA. 

a reduction of the discharge to the morning-drop, and 
the almost total disappearance of the mucus in the first 
part of the urine. Pain on urination, if previously pres- 
ent, will also have disappeared. When this stage has 
been entered upon, or if this is the condition of the ure- 
thra when the patient first applies for treatment, the in- 
ternal administration of remedies should be discontin- 
ued or ignored, unless the urine is unduly acid ; or the 
patient is anreinic and depressed in health, or if there is 
present a constitutional dyscrasia, such as syphilis or 
tuberculosis ; or if the patient has a rheumatic, lithaemic, 
or gouty diathesis ; or is a dyspeptic. Any of these con- 
ditions may exert an unfavorable influence on the prog- 
ress of a chronic urethritis, and if present, should receive 
vigorous treatment. The point to be emphasized is that 
in the treatment of the urethra we should not be mere 
specialists, but should look at the patient from the broad 
stand-point of the physician, instead of seeing him only 
through his urethra. 

Granted, however, that in the hypothetical case under 
consideration there is only the urethra to deal with and 
that the time for its local treatment is ripe, the first thing 
to be done is to pass a sound the full size of the urethra. 
If the meatus is noticeably narrow and offers an impedi- 
ment to the passage of the sounds, it should be cut on 
its floor, with a knife or the obstructing fold of muco- 
cutaneous tissue may be snipped with a pair of scissors. 
The incision, however, should be only large enough to 
readily admit of the passage of the largest sound which 
we estimate will be passed into the urethra. 

The passage of the sound is followed by an endoscopic 
examination to determine the nature, extent, and location 
of the urethral lesions, and to permit of the local applica- 



CHRONIC ANTERIOR URETHRITIS. 105 

tion of remedial agents to the inflamed areas. For this 
purpose an endoscopic tube a little smaller than the 
sound that has been passed is selected, and passed into 
the urethra. If the history of the case and the results of 
the examination of the urine excludes the implication of 
the posterior urethra, in the inflammatory process, the 
tube need not be inserted farther than the membran- 
ous urethra, otherwise it should be inserted to the vesi- 
cal orifice and the urethra inspected as the instrument 
is withdrawn. If the caput gallinaginis is swollen and 
inflamed its surface is swabbed with a solution of ni- 
trate of silver varying- in strength from twenty to sixty 
grains to the ounce. The first application should be 
weak, the stronger solution being held in reserve until 
the effect of the weak application has been observed. 
As the endoscope is withdrawn, patches of granulation 
tissue, as they appear, should be freely touched with the 
silver solution. Simple catarrhal areas should only be 
lightly touched with a weak solution. 

It is necessary to guard against applying the solution 
too freely, as harm may be done by the superfluous solu- 
tion extending beyond the intended limits and impli- 
cating healthy areas. The swab consists of a piece of 
match-wood cut to the proper length and tipped with cot- 
ton. These sticks may be obtained at any match-factory ; 
they are inexpensive and should be destroyed as soon as 
used. I use in preference to the match-wood willow rods 
cut to the proper length ; they are tougher than match- 
wood, and cut with a rough end that facilitates the fixa- 
tion of the cotton ; they may be obtained of the proper size 
at any place where street-sweepers are made or repaired. 

Having completed the endoscopic examination and 
treatment, and made a note of the results, the patient is 



106 DISEASES OF THE UBETHRA. 

directed to use, two or three times daily, a mild injection, 
and is requested to return on the third or fourth day for 
a renewal of the treatment. In some cases further en- 
doscopic treatment is unnecessary, although this is ex- 
ceptional, as I am partial to this method of treatment. 
It frequently happens that at first we must devote our 
whole energies to the restoration of the urethra to its 
normal resiliency and calibre. In other words, we must 
promote the absorption of chronic inflammatory exu- 
dates. This is accomplished by gradual dilatation, as- 
sisted in rare cases by internal urethrotomy. 

A solution of iodine, one part ; iodide of potassium, ten 
parts ; and glycerin, one hundred parts, is of great value 
in facilitating the absorption of urethral exudations, if 
it is painted over the indurated areas. An ointment of 
adeps lanse hydrosus, U. S. P., containing nitrate of 
silver, may be advantageously used instead of the solu- 
tion of the latter. It has the advantage that its action 
on the urethra is more prolonged, and the wool-fat tends 
t( > promote the absorption of the silver. A solution of sul- 
phate of copper, 1 to 20, is often used by some surgeons 
as a substitute for the silver solution ; it is sometimes ad- 
vantageous to alternate the use of the silver and copper. 

The above method of treatment cannot be followed in 
every case. There are certain individuals whose ure- 
thra is always too sensitive to permit of endoscopic 
manipulation, and in such cases we may resort to deep 
urethral injections, using the common deep urethral 
syringe. Where this is used a much weaker solu- 
tion must be applied than by the endoscopic method, 
as it is difficult to limit the distribution of the fluid 
which usually traverses areas where the urethra is 
healthy. Thus a very few drops placed in the bulbous 



CHRONIC ANTERIOR URETHRITIS. 107 

urethra will be squeezed forward by the collapsing- of 
the urethra, until it escapes at the meatus. This method 
is particularly valuable in the treatment of the posterior 
urethra, but has also a limited application in the an- 
terior urethra. 

There is considerable routine about this treatment, in 
defence of which I may plead that almost eveiy one's 
experience ultimately brings him to a point where he 
uses but few remedies, which the test of time and ex- 
perience has shown to be the most reliable, and nitrate 
of silver seems to be the remedy par excellence for the 
treatment of chronic inflammation of the mucous mem- 
branes, wherever its application can be made, and is in 
constant use for this purpose by the ophthalmologist and 
laryngologist, as well as by the genito-urinary surgeon. 

We may briefly sum up the treatment of chronic Ure- 
thritis as follows : 

Local treatment should not be attempted during an 
exacerbation of the inflammation. The urethra should 
be restored to its normal calibre and resiliency by 
gradual dilatation with sounds. The meatus should be 
cut if necessary, but internal urethrotomy should be 
avoided when possible, on account of its mortality. If 
the urethra is not too sensitive, local treatment with 
the endoscope should be employed in conjunction with 
gradual dilatation. Injections may or may not be used 
throughout the treatment, their use being determined to a 
great extent by the degree of catarrhal inflammation that 
may be associated with the other lesions of the urethra. 

In conclusion, it may be well to sound a note of warning 
on the subject of overtreatment of the urethra. It not 
infrequently happens that a chronic inflammation of the 
urethra is maintained by the very means instituted for 



108 DISEASES OF THE URETHRA. 

its removal. Following - the local treatment of the urethra 
there may be an undue amount of inflammatory reaction. 
If in such a case the treatment is repeated before the sub- 
sidence of the reaction it will be readily seen how the 
condition may be aggravated instead of benefited. In 
the treatment of chronic urethritis, if the disease makes 
unsatisfactory progress without an obvious cause for so 
doing, it is the part of wisdom to abandon for a time all 
local treatment and watch the progress of the case, aided 
only by such internal remedies as will serve to keep the 
urine from being in itself an irritant. It may be well to 
once more remind the reader that many cases of chronic 
urethritis do badly because there is a constitutional dys- 
crasia or diathesis present, whose treatment and correc- 
tion is as important for the cure of the diseased urethra 
as is the treatment of the urethra itself. There is a va- 
riety of chronic urethritis sometimes seen which deserves 
special mention because of its peculiar obstinacy in yield- 
ing to the ordinary modes of treatment. It is usually met 
with in those who, while apparently enjoying good health, 
are, nevertheless, very susceptible to catarrhal affections. 
If such a patient contracts a gonorrhoea it is prone to be- 
come chronic, but differs from the ordinary chronic ure- 
thritis in the fact that it continues to secrete a profuse 
purulent discharge, which may be equally as abundant as 
in the acute attack, but is not associated with the inflam- 
matory symptoms of the latter. In these cases the best 
results are obtained from daily irrigations of the urethra 
with a solution of nitrate of silver 1 to 1,500, potassium 
permanganate 1 to 1,000, or a solution of bichloride of mer- 
cury 1 to 15,000, using the apparatus shown in Fig. 11. 

It is probable in these cases that in addition to the 
gonococci other pyogenic micro-organisms luxuriate in 



CHRONIC ANTERIOR URETHRITIS. 109 

the urethral mucosa. When the free discharge has been 
subdued these cases are amenable to the ordinary modes 
of treatment, but under any circumstances they are, to 
say the least, unsatisfactory. 

One of the most difficult questions to answer is, when 
is a patient who has had a gonorrhoea, acute or chronic, 
justified in resuming sexual intercourse ? This question 
is frequently propounded, and the physician who answers 
it assumes a serious responsibility. Mistakes on his part 
are not always avoidable, and when made are liable to be 
followed by serious reflections by the patient on the ac- 
curacy of his judgment. Extreme caution should there- 
fore be exercised in this matter. If the patient is just re- 
covering from an acute attack of gonorrhoea, intercourse is 
out of the question if there is the least discharge, and for 
some time afterward — long enough to be sure that there 
will be no relapse. The greatest difficulty, however, is 
experienced in determining the infectiousness of chronic 
urethral discharges. We cannot apply the same sweep- 
ing rule in this case that we do in acute urethritis ; for 
many chronic urethral discharges are not infectious, and 
forbidding a patient to assume marital relationship on 
the ground of the existence of a discharge, or the pres- 
ence of urethral threads in the urine, would often entail 
needless disappointment and frequently disrupt conjugal 
relationship. It goes without saying that if the discharge 
contain gonococci it is infectious. This point cannot, 
however, be always easily determined. Eepeated exami- 
nations may give negative results, and yet the gonococci 
-be present, but in such scant numbers as to escape detec- 
tion. It has been observed that the discharge during 
the exacerbation of a chronic urethritis contain gonococci 
in much greater numbers than during the period of qui- 



110 



DISEASES OF THE URETHRA. 



escence. This is made use of by purposely exciting an 
exacerbation, and then examining- the discharge, an in- 
jection of nitrate of silver, or preferably a strong solution 
of bichloride of mercury, on account of its destructive in- 
fluence on extraneous micro-organisms, is used for this 
purpose. Repeated microscopic examinations are neces- 
sary before we can positively state that gonococci are 
absent from the secretion. Finger refuses to sanction in- 
tercourse as long as pus corpuscles are found in the se- 
cretion. It will be seen therefore that this subject is not 
an easy one to settle, and the physician will pursue the 
wisest course who, in case of doubt, either advises against 
intercourse or refuses to accept the responsibility, if the 
patient is determined to decide the matter for himself. 

It may be of service to append the results of the elab- 
orate researches by Professor Goll on 1,046 cases, showing 
the period at which gonococci were found. The secretion 
from each of these cases of urethritis were examined from 
three to fourteen times : 



Duration since Infection. 



4 to 5 weeks 

6 " 

7 " 

2 months 

3 " 

4 " 

5 ' l 

6 « 

7,8,9" 

1 year 

H " 

2 years 

4 " !!."!!!".".! 

5 " 

6 and more years 



Number of Gonococci Negative re- 
cases, found. suite. 



85 
54 
35 
75 
70 
62 
43 
55 

108 
83 
76 

135 
80 
37 
20 
22 



Percentage of 

occurrence of 

gonococci. 



13 


49 


8 


35 


8 


47 


21 


87 


12 


71 


7 


69 


7 


128 


2 


78 




37 




20 


.... 


22 



CHAPTEE XI. 
THE POSTERIOR URETHRA. 

Anatomy. 

The posterior urethra, the deep urethra, the prostatic 
urethra, and the neck of the bladder are almost synony- 
mous terms and are in constant use by the profession. 
There is, however, a considerable degree of vagueness 
regarding- the functions of the part which has received 
the- names given above, and a still greater lack of 
appreciation of the importance of the diseases to which 
this part of the urethra is liable. 

In order to appreciate the latter it is of the first 
importance that we understand the former, therefore no 
apology is needed if, in the preamble to the diseases of 
the posterior urethra, the anatomical and physiological 
part of the subject be detailed at length, although part 
of it has already been described in the first part of this 
work. 

The urethra is divided anatomically into the pendu- 
lous, the bulbous, the membranous, and the prostatic por- 
tions, but in the consideration of its disease we will ignore 
the anatomical classification and adhere to the clinical 
division of an anterior and a tposterior urethra, for we 
find that the diseases of the urethra are, to a certain 
degree, limited to either the anterior or the posterior 
portions of the urethra, and when a disease extends 



112 



DISEASES OF THE URETHRA. 



from one division to the other, the extension is often 
manifested by the onset of an entirely new group of 
symptoms. The reason for this clinical division is a 
purely anatomical one, namely, the arrangement of the 
circular muscular fibres of the urethra, which prevade 
the entire submucous tissue, but which at certain points 
are collected into distinct bundles, which grasp the 
urethra more or less tightly and act as a barrier to the 
passage beyond it of the contents of the bladder or of the 
urethral secretions. It is of the highest importance that 
we understand the arrangement of these muscular bands, 
which is as follows : At the vesical orifice of the urethra 
there is a bundle of unstriated circular muscular fibres 
which surrounds the urethra. This muscle is called the 
internal sphincter of the bladder, and serves when the 
bladder is not distended to prevent the passage of the 
urine into the urethra. As the bladder becomes dis- 
tended the tension on its walls acting on the fixed point, 
namely, the vesical orifice of the urethra, tends to pull 

the latter open (Fig. 
33). Up to a certain 
point the internal 
sphincter is able to 
withstand the pull of 
the bladder, but it is 
a weak muscle, and 
yields just as soon as 
*%£ the bladder is well 

Fig. 33.— Diagram Showing the Muscles of the filled, W r hen the COU- 
Posterior Urethra and the Effect of a Dis- tentg of ^ ^^ 
tended Bladder on the Internal Sphincter. 

leak into the poste- 
rior urethra, and were we dependent solely on this mus- 
cle for the retention of the urine, dribbling would take 




THE POSTERIOR URETHRA. 113 

place. Fortunately, however, there is another and 
stronger sphincter, which has also the additional advan- 
tage that it is partly under the control of the will, so that 
it can be voluntarily increased or diminished in force as 
occasion demands. This muscle is called the external 
sphincter, and is composed of two circular bands which 
surround the urethra at, and immediately in front of, the 
apex of the prostate gland. 

The first is a band of striated and non-striated muscu- 
lar fibres, situated at the apex of the prostate. The 
second is called the compressor urethra. It is a volun- 
tary or striated muscle, and lies between the two layers 
of the triangular ligament, to which and to the ischio- 
pubic rami on either side it is attached. Weaving itself, 
in various directions, above, below, and around the 
membranous urethra, it forms, with the circular muscle 
situated at the apex of the prostate, the external 
sphincter of the bladder. This sphincter is much more 
powerful than the internal sphincter, and therefore offers 
a greater resistance to the passage beyond it of either the 
contents of the bladder or of the urethral secretions, and 
to this fact the clinical division of the urethra into 
anterior and posterior portions is due. That part lying 
in front of the external sphincter is called the anterior 
urethra, and that portion lying posterior to the external 
sphincter is called the posterior urethra. 

The external sphincter, which so firmly grasps the 
membranous portion of the urethra, acts as a barrier 
to the passage backward beyond this point of the 
secretions from the anterior portion of the urethra. 
In gonorrhoea it is chiefly through the medium of the 
urethral secretion that the disease extends along the 
urethra, therefore this disease, as a rule, does not extend 



114 DISEASES OF THE URETHRA. 

beyond the external sphincter. When, however, from 
any cause the gonorrhceal process extends beyond this 
point, there is nothing- to prevent the invasion of the 
entire posterior urethra, since the external sphincter will 
not permit the escape forward of the infective secretion ; 
the only escape for it, if abundant, is backward, through 
the weak internal sphincter, into the bladder. If, how- 
ever the secretion is scant it may simply collect in the 
posterior urethra, until washed out in the act of urination. 
The important point to remember in this connection is that 
in an inflammation limited to the posterior urethra, the 
discharge does not escape forward but backward toward 
the bladder. A posterior urethritis may therefore exist 
without any visible discharge, except such as may be 
detected by an examination of the urine. 

The importance of understanding the muscular ar- 
rangement of the posterior urethra is, perhaps, from a 
clinical stand-point, of less value than the appreciation of 
its sensory and sexual functions. 

The posterior urethra is the most sensitive portion of the 
whole urinary tract to the stimulus to urinate. If a sound 
is passed along the urethra, the moment it enters the 
prostatic portion it gives rise to an intense desire to 
urinate, even if the bladder is empty, while if the instru- 
ment be inserted into the bladder, its contact with the 
latter does not perceptibly increase the desire. If a 
weak solution of nitrate of silver be injected into the an- 
terior urethra, it gives rise to a burning sensation, with- 
out any accompanying desire to urinate ; but if the same 
solution be injected into the posterior urethra, the desire 
to urinate predominates over the burning feeling. Press- 
ure of the finger within the rectum against the prostatic 
urethra gives rise to the desire to urinate. 



THE POSTERIOR URETHRA. 115 

Under normal conditions the stimulus to urinate only 
arises when the bladder is full, and a little of the urine 
has escaped past the weak internal sphincter into the 
posterior urethra, where its presence sets up the desire 
to urinate. If the bladder becomes much distended, the 
posterior urethra virtually forms a part of the bladder, 
since it freely communicates with the latter (Fig-. 33), and 
under these circumstances is deserving of the appella- 
tion so frequently given, "neck of the bladder." When 
this takes place the control of the urine depends entirely 
on the grasp of the external sphincter, which may require 
a constant volitional impulse to enable it to withstand 
the force of the detrusor muscles of the bladder. 

"When the bladder is distended it can readily be 
shown that the posterior urethra forms a portion of 
the bladder by inserting a catheter, with the eye on the 
tip, just beyond the compressor urethra, when the urine 
will begin to flow and continue until the distention of the 
bladder is relieved. The bladder, however, can only be 
completely emptied by inserting the tip of the catheter 
beyond the internal meatus, thus demonstrating that 
when the bladder is not distended it is shut off from the 
posterior urethra. 

It will be readily understood, therefore, why it is that 
in all affections of the posterior urethra which increase 
its sensibility frequent micturition is a prominent symp- 
tom. If the sensibility is very acute, simple contact of 
the vesical orifice of the urethra with the contents of the 
bladder will give rise to an intense desire to urinate, as 
may be witnessed in acute posterior urethritis of gonor- 
rheal origin, often miscalled gonorrhceal cystitis. It 
often happens, however, in these cases that the vesi- 
cal aspect of the internal meatus is inflamed, and in such 



116 DISEASES OF THE UKETHKA. 

cases the desire to urinate will be felt before any urine 
has leaked into the posterior urethra. The same de- 
sire to urinate is often observed in persons suffering 
from vesical calculus. "When in the erect position the 
stone gravitates against the neck of the bladder and 
frequent micturition is the result ; while if he be in the 
recumbent position the stone gravitates away from the 
neck of the bladder, and micturition becomes less fre- 
quent. 

When the hyperesthesia of the posterior urethra is 
less acute, as in chronic catarrhal affections, the desire 
to urinate may not be abnormally frequent, the stimulus 
not originating until the distended bladder has dilated 
the internal sphincter and the urine has leaked into the 
posterior urethra, but when this has taken place the de- 
sire to urinate is more urgent than normal, and the pa- 
tients will frequently make this the chief burden of their 
complaints. 

Aside from its relationship to the act of micturition 
the posterior urethra bears a no less important relation 
to the sexual and nervous systems. On its floor are the 
terminal openings of the ejaculatory ducts as well as a 
number of prostatic glands, whose secretion is intimately 
associated with the sexual act. These ducts and glands 
not infrequently participate in the inflammatory diseases 
of the posterior urethra, setting up, by a process of ex- 
tension, an epididymitis or a prostatitis, as the case may 
be. Of still greater importance to the urethral surgeon 
is the peculiar elevation on the floor of the prostatic ure- 
thra, called the caput gallinaginis (Fig. 34). It projects 
about an eighth of an inch from the floor of the urethra, 
and is composed of mucous membrane and erectile tissue. 
The ejaculatory ducts open on the anterior aspect of its 



THE POSTERIOR URETHRA. 



117 



lateral borders. Within it, in a direction downward and 
backward, is the sinus pocularis, a cul-de-sac about a 




Fig. 34. — The Lower Part of the Bladder, and the Prostatic, Membranous, and 
Bulbous Parts of the Urethra, Opened from Above. (Allen Thompson.) 

quarter of an inch in length, which is the analogue in 
the male of the uterine cavity in the female. 

It is important, in order to understand many of the 
phenomena manifested in diseased conditions of the 
posterior urethra and prostate gland, that we appreciate 



118 



DISEASES OF THE URETHRA. 



the analog-cms relations of the male and female organs of 
generation. For this purpose the accompanying dia- 
grams are given. In Fig. 35 the common genital organs 
before the differentiation of sex is portrayed. In Fig. 36 
the female genital organs are shown to be developed from 
the ducts of Muller, the free extremity forming the Fal- 
lopian tubes, the coalesced portion forming the uterus 
and vagina. In Fig. 37 the ducts of Muller play a much 
less important role, and are entirely obliterated except 




Fig. 35. 



Utricle or coalesced 
portion of the ducts of -Muller 
uihich with the surrounding pro- 
state is the analogue of the literut 
and l-'kgina. 

. Fig. 37. 



at the lower extremity, where they coalesce to form the 
utricle or sinus p ocularis, the wall of the tubes forming 
the prostate gland. 

In the infantile urethra the caput gallinaginis and 
utricle are much larger proportionately than in the adult 
urethra. In Fig. 38 the development of the organs of 
generation is shown in detail. 

The prostate gland, especially in the neighborhood of 
the urethra and caput gallinaginis, is very rich in nerves 
containing ganglia and Pacinian corpuscles, which are 
usually only found in very sensitive organs. Like the 




Fig. 3S.— Diagrammatic ^Representation of the Development of the Genito-urinary 
Apparatus. (Henle.) 

I, Embryonic condition, in which there is no distinction of sex ; II, female form ; III. male 
form. The dotted lines in II and III represent the situations which the male and female 
genital organs assume after the descent of the ovaries and testicles. The small letters in II 
and III correspond to the capital letters in I. 

I.— A, kidney; B, ureter : C, bladder; D, urachus, developed into the median ligament of the 
bladder; E, constriction which becomes the urethra; F', Wolffian body; G, Wolffian duct, 
with its opening below, G' ; H, duct of Muller, united below, from the two sides into a sin- 
gle tube, J, which presents a single opening, J', between the openings of the Wolffian 
ducts ; K, ovary or testicle ; L, gubernaculum testis or round ligament of the uterus ; 
M, genitourinary sinus; N, O, external genitalia.— II (Female), a, kidney; b, ureter; 
c, bladder ; d. urachus ; e, urethra ; f, remains of the Wolffian body (parovarium) ; g, rem- 
nant of the Wolffian duct; h, Fallopian tube; i, uterus; i', vagina; k, ovary; 1, round 
ligament of the uterus ; m. extremity of the urethra ; n. clitoris ; n', corpus cavernosum of 
the clitoris ; n", bulb of the vestibule ; o, external genital opening ; p, excretory duct of 
the gland of Bartholinus. — III (Male), a, kidney ; b, ureter; c, bladder; d, urachus; e, 
urethra; f, epididymis; g, vas deferens; g', seminal vesicle; g", ejaculatory duct; h. i, 
remains of the duct of Muller ; k, testicle ; 1, gubernaculum testis ; n, n', n", urethra and 
penis ; o, scrotum ; p, gland of Cowper ; q, prostate. 



120 DISEASES OF THE URETHRA. 

uterus it is supplied by the hypogastric plexus of the 
sympathetic aud pudendal plexus of the sacral nerves. 
The pudic nerve, a branch of the sacral plexus, is dis- 
tributed to the urethra, glans penis, and sphincter ani ; it 
also supplies the integument of the penis, scrotum, and 
perineum. The identity in nervous supply explains the 
relationship between the pain felt in the glans penis as 
the result of irritation of the neck of the bladder, and the 
teasing neuralgic pains that are often felt in the integu- 
ment over the pubes, scrotum, perineum, and thighs, as 
the reflex manifestations of an unhealthy posterior ure- 
thra. The sphincter ani and compressor urethrae be- 
ing supplied by the same nerve, the intimate association 
of retention of urine with operations on the rectum is 
readily explained. ■ 

The prostate gland and uterus bear a close relation- 
ship to each other, since they are developed from similar 
rudimentary organs, resemble each other in structure, and 
are identical in their nervous supply. It is not to be 
wondered, therefore, that in some respects they are sus- 
ceptible to similar diseases, the reflex manifestations of 
which, in the male as in the female, often border on the 
hysterical. 



CHAPTEK XII. 
ACUTE POSTEEIOR URETHRITIS. 

Etiology. 

Befobe we realized the clinical distinctions between 
the diseases of the anterior and posterior urethra, pos- 
terior urethritis was not recognized as an entity, this dis- 
ease being referred to the bladder although occasionally 
an attempt was made to localize it to the neck of the 
bladder, the latter, in the professional mind, vaguely con- 
sisting of a prolongation of the bladder which connected 
it with the urethra. On the other hand on the recogni- 
tion of the sharp anatomical and clinical division of the 
urethra into anterior and posterior portions, there was 
a tendency to divorce their diseases, a procedure which 
to a certain extent was justified by the diversity of the 
symptoms and operative treatment of the diseases of 
these two portions of the urethra and still holds good in 
so far as it seems advisable to treat of their diseases 
separately. 

It is probable that an error has been committed in fail- 
ing to recognize the presence of some of the milder in- 
flammations of the posterior urethra when associated 
with acute anterior urethritis, and in failing to recognize 
that acute posterior urethritis is often not sharply limited 
posteriorly to the internal meatus, but may involve its 
vesical aspect, particularly in the neighborhood of the 
trigone. 



122 DISEASES OF THE URETIIIJA. 

There is at tlie present time a growing- tendency to the 
belief that acute posterior urethritis is such a common 
concomitant of acute anterior urethritis that it should be 
considered exceptional when it does not accompany the 
latter disease. The advocates of this theory claim that 
the disease is often overlooked and the frequency of its 
occurrence much underestimated, and also that it appears 
much earlier in the course of acute anterior urethritis 
than has generally been supposed. Statistics have been 
given to show that in eighty per cent, of cases of acute 
anterior urethritis a posterior urethritis is also present. 
To account for this surprising statement the theory has 
been advanced that infection of the whole urethra takes 
place within a day or two of the onset of the disease, by 
means of the lymphatics, extension on the free surface, or 
by continuity of tissue holding a minor position in the 
rule of infective channels. 

I am perfectly willing, as will be shown later, to concede 
the frecpiency of chronic posterior urethritis, but neither 
the experience I have had, nor the investigations I have 
made, warrant me in entertaining the belief that this dis- 
ease is nearly as frequent a sequence of acute anterior 
urethritis as is indicated above. If Ave believe that infec- 
tion of the deeper portions of the urethra takes place 
through the medium of the lymphatics, then we can 
readily conceive that the posterior urethra would rarely 
escape infection ; but, believing in neither, I must hold 
that acute posterior urethritis should be regarded as a 
complication, not as an essential part of a gonorrhoea. 
In fact it must be considered the most serious complica- 
tion liable to arise in the course of acute anterior ure- 
thritis, since it is a necessary forerunner of gonorrhocal 
epididymitis, cystitis, and pyelitis. 



ACUTE POSTERIOR URETHRITIS. 123 

Nature has interposed a barrier between the anterior 
and posterior urethra in the tonic contraction of the mus- 
cles which grasp the urethra as it passes between the 
layers of the triangular ligament. That this barrier is not 
an impermeable one is evident from the fact that the secre- 
tion containing the gonococci will often, in spite of all 
precautions, pass the barrier and infect the deep urethra. 
It is not until after the gonococci have invaded the entire 
length of the anterior urethra, which is usually in the third 
week of the disease, that the posterior urethra becomes 
infected. Injections in the early stages of a gonorrhoea, 
or the passage of instruments, may carry the gonbcocci- 
laden pus to the deep urethra, before the invasion of the 
anterior urethra is complete. This is one of the most 
serious objections to the use of injections, or the passage 
of instruments, early in the disease, for it has been ob- 
served that posterior urethritis not only occurs earlier, 
but also oftener, under such circumstances. 

The moment the gonococci have succeeded in passing 
the natural barrier between the anterior and posterior 
urethra there is nothing to prevent the rapid infection of 
the whole posterior urethra, for the point of least resistance 
is toward the bladder, in which direction the infective secre- 
tion rapidly travels, contaminating the urethra in its course. 

The acme of posterior urethritis is therefore rapidly 
reached, and the period of decline is usually established 
at a much earlier period, dating from their respective in- 
ceptions, than is acute anterior urethritis. Acute pos- 
terior urethritis, however, is more liable than acute 
anterior urethritis to lapse into the chronic stage. 

When an anterior urethritis is complicated by a pos- 
terior urethritis the intensity of the former usually 
rapidly decreases synchronously with the development of 



124 DISEASES OF THE URETHRA. 

the latter. Why such should be the case is difficult of 
explanation, but it is not without a parallel. It is a matter 
of common observation that the development of a tuber- 
cular abscess in one situation will check the progress of a 
tubercular lesion in another ; or the development of pul- 
monary tuberculosis will frequently arrest the progress 
of a pre-existing tubercular disease of the bones. It is 
not uncommon, on the other hand, for the subsidence of 
a posterior urethritis to be marked by an exacerbation 
of the inflammation in the anterior urethra. Why this 
should be so has not received a satisfactory solution, and 
must therefore be left an open question. 

The intensity of a posterior urethritis is very variable. 
It may be equally as violent as in the anterior urethra, 
and associated with much more distressing symptoms. 
More often it is of a milder grade, being subacute or 
chronic from the beginning. 

If infection of a posterior urethra takes place early 
in the course of a gonorrhoea, it is liable to be acute and 
associated with violent symptoms ; if infection takes 
place late in the course of a gonorrhoea it is usually sub- 
acute, and often associated with symptoms so mild that 
the disease may be overlooked. The variation in the 
intensity of the inflammation in these cases is probably 
due to a difference in the virility of the gonococci. When 
infection takes place early, the gonococci are more viru- 
lent than at a latter stage, when the gonococci have 
been weakened by the propagation of successive genera- 
tions in the same soil. 

Acute posterior urethritis is rarely met with except as 
a sequence of a gonorrhoea ; it may be caused by violent 
instrumentation, such as the clumsy passage of the sound 
or catheter, or by the impaction of a small calculus iii the 



ACUTE POSTERIOR URETHRITIS. 125 

prostatic urethra, or it may be inflamed in acute prostati- 
tis, but these cases form such a small part of the whole 
that they need not be considered in the present article, 
which deals chiefly with the diseases of the urethra that 
are due to infection. 

The period at which a posterior urethritis may develop 
in a gonorrhoea will vary very much, its onset and the 
time of its appearance depending- to a great extent on the 
form of treatment to which the anterior urethra has been 
subjected, being not only more frequent, but also appear- 
ing earlier, when injections or instrumental treatment 
is instituted, than when local treatment is avoided. It 
will be found that the majority of cases do not develop 
until after the gonorrhceal inflammation has extended to 
the bulbous portion of the urethra ; this will usually be 
found between the second and fourth week of the disease. 

Heissler states that in fifty cases which he observed 
posterior urethritis occurred — 

In the 1st week after infection in 20 per cent. 
" " 2d " " " " 34 " " 

" " 3d " " " • " 14 " " 

" " 4th " " " " 20 " " 

Finger, commenting on this table, remarks that 
" despite careful observation I have never observed such 
an early development in cases which were not treated 
locally." 



OHAPTEK XIII. 

ACUTE POSTEEIOE UEETHEITIS. 

Symptoms. 

The symptoms of acute posterior urethritis centre 
chiefly around the fact that the mucous membrane of the 
posterior urethra is the most sensitive of the whole uri- 
nary tract to the stimulus to urinate. In health the 
stimulus to urinate arises when the bladder is filled and a 
drop of urine trickles into the posterior urethra, or neck 
of the bladder. In disease this sensibility is abnormally 
acute, so that the ordinary stimulus is increased man- 
ifold. Frequent and painful micturition is, therefore, 
the characteristic symptom of acute posterior urethritis. 
The intensity of this symptom varies with the grade of 
the inflammation and the condition of the urine. If the 
inflammation is very acute, and especially if it has ex- 
tended to the vesical aspect of the urethral orifice, then 
the case becomes most distressing-. The desire to urin- 
ate is constant. No sooner have a few drops of urine 
collected in the bladder than violent vesical tenesmus sets 
in, the patient is powerless to restrain the act, and the 
crowding of the vesical walls against its neck causes not 
only intense pain, but frequently ruptures the capillaries 
in the mucous membrane so that a few drops of blood 
often mark the termination of the act. No sooner has 
the pain of a spasm subsided than the expectations of 
relief are rudely shattered by the onset of another spasm, 
and thus the case goes on, in its pitiable course. Not in- 



ACUTE POSTERIOR URETHRITIS. 127 

frequently the swelling 1 of the mucosa or a spasm of the 
sphincters causes retention of urine, and then we have to 
deal with a condition that is truly agonizing. 

The milder grades of inflammation are associated with 
correspondingly milder symptoms, which may be man- 
ifested less by frequency or pain in urination than by a 
difficulty in restraining the act when once the desire has 
arisen. In these cases it is but fair to suppose that the 
inflammation is not of a severe grade, and has not in- 
volved the vesical aspect of the urethral orifice. Be- 
tween these extremes there may, of course, be various 
grades of inflammation, the symptoms of which will be 
readily understood, and need not be entered into. 

The diagnosis of posterior urethritis, in the acute 
stage, can usually be made from the subjective symptoms 
alone. Given a case of gonorrhoea which, between the 
second and fourth week, develops the symptom of fre- 
quent and painful urination, the diagnosis may be read- 
ily made without much further questioning. If, how- 
ever, there is a doubt in the matter, it can be set at rest 
by an examination of the urine. For this purpose let the 
patient pass his urine, preferably the first passed in the 
morning, into three glasses. If there is only an anterior 
urethritis present the first glass will be turbid from the 
fact that the first part of the urine washes out the pus 
and desquamated epithelium from the anterior urethra. 
The second vessel will be clear or slightly turbid, if the 
first urine has not entirely cleansed the urethra. The third 
glass will be clear because the urine it contains has passed 
over a urethra that had previously been washed clean. 

If, however, there is also an acute posterior urethritis 
present, the first glass will be turbid. The second will 
also be turbid, but to a lesser degree, dep ending on the 



128 DISEASES OF THE URETHRA. 

severity of the posterior urethritis. The third glass will 
be slightly turbid, for it will still contain some of the se- 
cretion that has passed from the posterior urethra into 
the bladder. If the inflammation is of a low grade, with 
scant secretion, or if a short interval has elapsed between 
the acts of urination, the third, and sometimes the second 
glass may be clear, for no secretion may have passed 
backward into the bladder. Any doubt that may ex- 
ist as to the involvement of the posterior urethra may be 
settled by first washing out the anterior urethra with an 
irrigator, and then directing the patient to urinate into 
two vessels. If pus threads are still present they must 
come from the posterior urethra, and will be found 
chiefly or altogether in the first part of the urine. 

It sometimes happens that in the expulsion of the 
List drops of the urine a number of delicate comma-like 
threads are squeezed out of the prostatic glands. These 
threads consist of moulds of the glands in the prostate, 
their appearance and the fact that they settle rapidly to 
the bottom of the vessel will differentiate them from any 
secretion derived from the bladder or higher portion of 
the urinary tract. 

A chemical examination of the urine will often reveal 
much more albumin than can be accounted for by the 
pus in the urine. This is probably due not to structural 
changes in the kidney, but to an increased intrapelvic 
pressure, caused by the vesical spasm. 

The pain of posterior urethritis is referred to the peri- 
neum, distinguishing it from the pain of cystitis, which is 
referred to the suprapubic region. A digital examina- 
tion of the prostate per rectum will usually evince an 
abnormal tenderness which may amount to a pain if there 
is marked involvement of its glandular stracture. 



CHAPTER XIV. 
ACUTE POSTERIOR URETHRITIS. 
Treatment. 

Every case of acute posterior urethritis is a serious 
one, and the physician and patient should both realize 
this at the outset. The simplest case may be the fore- 
runner of a prostatitis, an epididymitis, a cystitis, a pye- 
litis, or a pyelo-nephritis, even the life of the patient 
may be sacrificed to what at first may seem but a trivial 
complaint. 

The hygienic and dietetic rules laid down to govern 
the treatment of acute anterior urethritis should be rigor- 
ously observed. If the case is of a severe type, absolute 
rest in bed should be enforced, as a sine qua non to 
further treatment. Motives of secrecy or other causes 
that justify a patient with an anterior urethritis in fol- 
lowing his ordinary vocations must be thrown to the 
winds, and absolute rest secured at all hazards. This is 
rarely difficult to enforce, for even to the patient the 
case assumes such a serious aspect that the physician's 
orders are strictly obeyed. 

The same indications exist for the internal administra- 
tion of the balsams, ethereal oils, and the alkalies, as in 
acute anterior urethritis, the urine should be maintained 
in a neutral or slightly acid coudition. An alkaline urine 
should be avoided, for the reason that it has slightly irri- 
tating properties, and also because it facilitates the growth 
of micro-organisms and the decomposition of the puru- 



130 DISEASES OF THE URETHRA. 

lent secretion which flows from the posterior urethra 
into the bladder. 

If injections have been employed in the treatment of 
an associated anterior urethritis they should, be imme- 
diately discontinued. If the posterior urethritis is acute, 
this rule should be inflexible, for the importance of a co- 
existing anterior urethritis dwindles, by comparison, into 
insignificance, and for the time being its treatment should 
be ignored. 

It is a curious fact, however, as has already been men- 
tioned, that the onset of a posterior urethritis is usually 
marked by a diminution in the severity of the symptoms 
of the coexisting anterior urethritis. A valuable ad- 
junct to the treatment already indicated is the use of hot 
sitz-baths, which may be used from three to six times a 
day, the water being as hot as can be borne. Injections 
of hot water into the rectum will also ameliorate the symp- 
toms. The injections should be given with the patient 
lying on his left side, a quart of water at a temperature 
ranging from 110° F. to 130° F. should be used. 

If the desire to urinate is distressing, and the vesical 
spasms frequent, anodynes should be freely used, for the 
ill effects of such remedies on the gastrointestinal tract 
is the least of two evils when compared with the injuri- 
ous effect of constant vesical spasms crowding the ten- 
der walls of the neck of the bladder against each other 
and wearing out the unfortunate patient. 

Belladonna, on account of its antispasmodic action, is 
the remedy most often used, and is usually employed in 
combination with opium in a suppository as follows : 

Extracti opii gr. x. 

Extracti belladonna? gr. v. 

M. — Ft. suppositoria?, No. 10. Sig.: To be used as directed. 



ACUTE POSTERIOR URETHRITIS. 131 

The suppositories should be used sufficiently often to 
control the pain and spasm. If necessary the patient 
may be slightly narcotized ; care should be taken at the 
same time to prevent constipation. It is only in excep- 
tional cases that it is necessary to push the anodynes to 
the point indicated above ; as a rule it will be sufficient 
to use a suppository at bedtime to insure a comfortable 
night's rest. 

When the disease has passed into the subacute stage 
the balsams and anodynes may, with advantage, be dis- 
continued; the alkalies should, however, be used, if 



V= 




Fig. 39. — Keyes's Deep Urethral Syringe. 

necessary to insure a non-irritating urine. In this stage 
no remedy seems to afford such marked relief or to be 
so efficacious as the application to the neck of the blad- 
der of a weak solution of nitrate of silver. For this pur- 
pose a deep urethral syringe, such as Keyes's or Ultz- 
mann's, should be employed (Fig. 39). About twenty 
minims of a 1 to 4 grains to the ounce solution of nitrate 
of silver should be deposited in the anterior portion of 
the deep urethra, from which point it will rapidly spread 
along the whole posterior urethra. The superfluous so- 
lution which flows backward into the bladder will be 
neutralized by contact with the chlorides in the urine. 
The w r eaker solution should be used tentatively, and the 
application made with the utmost gentleness, otherwise 



132 DISEASES OF THE URETHRA. 

the traumatism inflicted will more than counterbalance 
the beneficial influence of the application. 

Immediately after the application there is a temporary 
increase in the vesical tenesmus which may last from a 
half to two hours, and should be anticipated, at least at 
the first application, by the use of a suppository one-half 
an hour previous to the application. After an interval of 
a day the application should be repeated. Its strength 
should be gauged by the severity of the reaction follow- 
ing the previous application. It will be found, however, 
that succeeding applications can be made stronger with- 
out a proportionate increase in the severity of the reac- 
tion. In cases that are subacute from the beginning 
this mode of treatment may be begun at once, for in this 
stage of the disease it is the sheet-anchor to which we 
should tie ; but it should not be forgotten that it may be 
an instrument for evil instead of good if infinite gentle- 
ness is not used in its manipulation. It is much more 
difficult to pass a solid instrument of small calibre, such 
as the deep urethral syringe, than to pass a large instru- 
ment like a steel sound, as the former is liable to push 
the mucous membrane of the urethra in front of it, form- 
ing a fold against which the instrument becomes en- 
tangled. 

As the severity of the symptoms subsides the interval 
between the injections should be lengthened to from 
three to five days, and maintained at this period until 
convalescence is established. 

When the disease has passed into the subacute stage 
the treatment of the anterior urethritis may be resumed. 



CHAPTEE XV. 
CHEONIC POSTEEIOE UEETHEITIS. 

Etiology and Pathology. 

Chronic inflammation of the posterior urethra, like 
chronic inflammation of the anterior urethra, is often a 
sequence of the acute form of the disease. The acute in- 
flammations of the posterior urethra are, however, more 
liable to become chronic than are the acute inflammations 
of the anterior urethra. This may be attributed to sev- 
eral causes, among which we may mention the greater 
hindrance to the escape of the inflammatory products, 
which are prone to collect in the posterior urethra, being 
barred anteriorly by the external prostatic sphincter 
and to a less extent posteriorly by the internal prostatic 
sphincter ; also to the greater difficulty encountered in 
the local treatment of the deep urethra, since injections 
as commonly used do not reach this point, and, finally, 
we may add the disturbing influence which the sexual 
system exerts, with particular force, on this part of the 
urethra. 

While a chronic inflammation of the anterior urethra is 
rarely found, except as the sequence of an acute attack, it 
is not so, however, in the deep urethra where a chronic in- 
flammation is frequently found without the pre-existence 
of an acute inflammation. This may be readily accounted 
for if we keep in view the relationship of the deep ure- 



134 DISEASES OF THE URETHRA. 

thra to the sexual functions. During- sexual excitement 
the caput gallinagiiiis becomes turgid from the overfill- 
ing of the lacunar spaces of the erectile tissue, which is 
found beneath the mucous membrane of this body, and 
swells to such an extent that it closes the urethral canal. 
It is this closure of the urethral canal which prevents the 
passage backward to the bladder of the seminal fluid 
during ejaculation, and renders it difficult or impossible 
to urinate while the penis is in a state of erection. 

Causes, such as sexual excesses, masturbation, and to a 
still greater extent, ungratified sexual desires, which in- 
crease to an unnatural degree either the duration or fre- 
quency of the congestion of this portion of the urethra 
are prone to set up an inflammatory disturbance, which is 
usually at first of but slight intensity, but, after long con- 
tinuance and repeated attacks, produces a low grade of 
chronic inflammation, which is manifested by a thickening 
and congestion of the mucous membrane and an hyper- 
trophy of the caput gallinaginis. Patients who have a 
rheumatic, a lithsemic, or gouty diathesis are so often 
the subjects of chronic posterior urethritis that a causa- 
tive relationship must be accorded to these diathetic con- 
ditions. With these factors at work, namely, in the order 
of their importance, gonorrhceal infection of the posterior 
urethra, disturbance of the sexual functions, and the 
rheumatic, lithaemic, and gouty diathesis, together with 
the difficulty encountered in the treatment of the diseases 
of the deep urethra, it is not to be wondered at that it is 
in this portion of the urethra, above all others, that we 
find chronic inflammatory lesions with the greatest fre- 
quency. This statement may not accord with those of 
other writers on the diseases of the urethra, but it is 
given, nevertheless, with a firm conviction of its accuracy, 



CHRONIC POSTEKIOR URETHRITIS. 135 

based on a careful consideration of the subject, and on 
the result of repeated endoscopic examinations, partly 
undertaken with the view of determining this point. 



Pathology. 

The anatomical changes in posterior urethritis bear a 
close resemblance to the changes in anterior urethritis. 
It is said by numerous writers that granulations are never 
found in the posterior urethra, although Desormeaux, the 
father of urethral endoscopy, has described them in this 
situation. The mucous membrane may be thickened, 
very vascular, and thickly studded with papillary out- 
growths, which contain minute blood-vessels, giving to 
the part the velvety appearance of the small intestine. 
In other cases the round-celled infiltration of the mucous 
and submucous tissues has gone on to the formation of 
connective tissue, producing a sclerosis and rigidity of 
the mucous membrane. The glands of the urethra are 
usually involved in the same process, which extends along 
and around the ducts into the substance of the prostate. 
The involvement of these glands may be quite extensive. 
In the early stages the process is usually, if mild, a 
desquamative catarrh ; if acute, a desquamative purulent 
catarrh. The latter condition is the cause of prostator- 
rhoea. Associated with and part of this condition is an 
enlargement or swelling of the prostate, from involvement 
of its glandular structure. The prostate is tender and 
frequently studded with nodules, caused by blocking of 
the orifice of the glands and the consequent formation of 
minute retention cysts within its substance. In the ad- 
vanced stage of the process the transformation of the peri- 
glandular infiltration into connective tissue produces, 



136 DISEASES OF THE URETHRA. 

first, compression and then destruction of the glands, 
while, pari passu, as a result of this destructive process, 
there is a progressive atrophy of the prostate. The most 
interesting changes, however, are to be found in the caput 
gallinaginis, which increases in size, sometimes to two or 
three times the normal. In addition to the thickening of 
its mucous membrane there is an hypertrophy of its 
underlying erectile tissue. The sinus pocularis and the 
ejaculatory ducts become involved in the inflammatory 
process, which, if it goes on to the formation of connec- 
tive tissue, produces a rigidity and stenosis, or even oc- 
clusion of these ducts ; it is doubtless the stenosis of the 
latter which produces the sharp pain often experienced, 
in cases of long standing posterior urethritis, at the mo- 
ment of ejaculation. 



CHAPTEK XVI. 

CHKONIC POSTERIOR URETHRITIS. 

Symptoms and Treatment. 

The symptoms of chronic posterior urethritis are de- 
pendent partly on the cause of the disease, and partly 
on the degree of involvement of the glandular structures 
which communicate with this portion of the urethra. 
When a chronic posterior urethritis is a sequence of the 
acute form of the disease, it is characterized either by a 
desire to urinate frequently, or more often by an increase 
in the intensity of the stimulus when once the desire has 
arisen. This is readily explained if we consider that 
when the bladder is filled a few drops of the urine leak 
into the posterior urethra, which, from its hypersesthetic 
condition, consequent on its inflamed state, sets up an 
acute desire to urinate, which, if resisted, may become 
within a short time so strong as to be uncontrollable. If 
the posterior urethritis owes its origin to disturbances in 
the sexual functions, then urinary disturbances are less 
prominent. In these cases, as a result of the long-con- 
tinued irritation of the exceedingly sensitive caput gal- 
linaginis, which, as we have seen, has a complex nervous 
supply, reflex nervous phenomena assume a predominat- 
ing influence in the symptomatology of the disease. 

If there is marked involvement of the prostatic glands, 
there is a feeling of weight and fulness in the perineum, 



138 DISEASES OF THE URETHRA. 

and frequently with the expression of the last drop of 
urine, or during" defecation, there is an expulsion of a 
whitish, glairy fluid, having a seminal odor, which is 
often a source of considerable alarm to the patient. This 
symptom, to which the name prostatorrhcea has been 
given, is caused by the squeezing of the prostate gland 
and the consequent emptying of its glandular secretion, 
by the compression of the levator ani and detrusor mus- 
cle of the bladder, or by the passage over the prostate (if 
hardened feces during defecation. Not infrequently the 
seminal vesicles are involved in the inflammatory pro- 
cess and a true spermatorrhoea may be present ; in this 
ease the secretion may be quite profuse and the patient's 
alarm all the greater. 

As a consequence of the hypenesthetic condition of 
the caput gallinaginis and the diseased condition of the 
ejaculatory ducts, pollutions are frequent ; for the same 
reason sexual congress is unsatisfactory and emissions 
are premature. The patient soon concentrates his 
thoughts on his malady, which he magnifies to an unlim- 
ited extent. He becomes hypochondriacal, and is in a fit 
state 1 to believe what any designing quack may tell him 
about lost manhood, premature decay, and the host of 
other evils so graphically portrayed in the current news- 
papers of the day. I admit that this is an extreme pict- 
ure of this neurotic condition, but it is one, however, 
which is not overdrawn, and not infrequently met with. 

The most common symptoms in mild cases with but 
little neurotic disturbance are, aside from the disturbance 
of the function of micturition, vague, ill-definable, but 
more or less constant uneasy sensations, or pains, over 
the pubes, inguinal region, glans penis, and inner surface 
of thighs ; and shooting pains, or, as the patient will 



CHRONIC POSTERIOR URETHRITIS. 139 

sometimes express it, a feeling as of a hot iron being- 
drawn along- the urethra (neuralgia of the urethra). 

Treatment. 

For the successful treatment of this disease it is essen- 
tial that we first of all secure the full confidence of the 
patient, and in no way can this be better or easier done 
than by an examination of the case that will be thorough 
enough to convince the patient that you understand your 
business. The patient will have already had sufficient 
experience of this sort to enable him to make a fair esti- 
mate of your ability from the manner in which you ex- 
amine him, and will make mental comparisons that are 
anything but flattering if you are careless or indifferent. 
Having secured the confidence of the patient it is well to 
clinch what has already been acquired, by a rational ex- 
planation of the nature and symptoms of the disease. 
"When the fears he has conjured up concerning his case 
are groundless, do not attempt to disperse them by ridi- 
cule. To the patient they are serious realities, only to be 
dissipated by a feeling of absolute confidence in your 
statements, backed up by your rational explanation of 
their groundlessness. When you have succeeded in se- 
curing both the patient's confidence and his perception 
of his symptoms at their proper value, the case is under 
favorable conditions for recovery, and you will have the 
co-operation of the patient during what may prove a 
tedious course of treatment. In many of these cases the 
treatment of a diseased imagination is often as important 
as the treatment of the diseased urethra, and unless the 
full confidence of the patient is obtained the best efforts 
will be met with but partial success. 

We may, for this purpose of treatment, classify with ad- 



140 



DISEASES OF THE URETHRA, 



vantage the cases of chronic posterior urethritis into two 
groups : those that are directly due to gonorrheal infec- 
tion of the posterior urethra, and those that are not of 
gonorrhceal origin. In the first 
group of cases the prominent symp- 
tom is a disturbance in the function 
of micturition. If, however, the 
case is of long standing, it may be 
indistinguishable, clinically speak- 
ing, from the second group in which 
neurotic symptoms predominate. 

In the first group there is either 
a frequency in passing water, or an 
abnormally acute desire to urinate 
when once the desire has arisen. 
Associated with this there may be 
a feeling of fulness or dragging in 
the perineum. In these cases the 
treatment does not differ materially 
from the treatment of chronic an- 
terior urethritis. The urine should 
be maintained, by the use of alka- 
lies and diluents, in as unirritating 
a condition as possible. Every sec- 
ond, third, or fourth day a cold 
Fig. 40. - Ultzmann's Ir- s t ee l sound, the full size of the 

rigating Catheter Syringe. , ... .. n , , , 

urethra, should be passed, and held 
in situ about one minute. 

Injections of nitrate of silver solution, 1 to 4 grains 
to the ounce, should immediately follow the use of the 
sound. The injection should be deposited, by the 
deep urethral syringe, in the posterior urethra, a few 
drops only being used. Ultzmann recommends the use 




CHRONIC POSTERIOR URETHRITIS. 141 

of an irrigating" catheter syringe (Fig. 40). The catheter 
is inserted into the posterior urethra, and the fluid 
slowly injected. If the bladder is capacious several 
syringefuls may be used, and the patient, at the conclu- 
sion of the treatment, requested to empty his bladder. 
It is obvious that only weak solutions must be used, 
otherwise the bladder would be irritated. The injections 
recommended in the treatment of acute anterior urethritis 
may be used for this purpose with perfect safety. 

The treatment indicated above will rapidly cure an 
ordinary case of chronic posterior urethritis that has not 
as an accompaniment, or rather as a symptom, reflex 
neurotic or sexual disturbances, in which the prognosis 
is much less favorable. 

In long-standing cases of posterior urethritis of gon- 
orrhceal origin, or due to such causes as ungratified sex- 
ual desires, sexual excesses, or masturbation, the treat- 
ment, to be efficient, must be more drastic. In these 
cases structural changes are often very deeply situated 
not only in the prostate, but may also extend along the 
ejaculatory ducts to the seminal vesicles ; prostatorrhoea, 
vesiculitis, pollutions, spermatorrhoea (true and false), 
are the complications we often have to deal with. To 
these may be added the morbid mental phenomena 
which these diseased conditions engender. It will read- 
ily be seen from this picture that the treatment of this 
variety of chronic posterior urethritis frequently offers 
difficulties that are well-nigh insurmountable. 

The caput gallinaginis is usually hypertrophied, and, 
if we pass a sound, the moment it is touched the patient 
experiences an intense, sharp, sickening pain. For the 
relief of this condition pressure and cold are efficacious. 
A large steel sound dipped in ice-water should be 



142 DISEASES OF THE URETHRA. 

passed, at regular intervals, or the psychrophor (Fig-. 41) 
may be used and a stream of ice-water passed through 
it for ten or fifteen minutes. 

In conjunction with the above treatment cauterization 
of the caput gallinaginis is useful. It has been recom- 
mended on the highest authority to use the solid stick 
of nitrate of silver for this purpose. I have never had 
the courage to adopt such heroic treatment, and there- 
fore hesitate to recommend it, although the desperate 
character of some of these cases would justify the adop- 
tion of almost any treatment, no matter how severe, that 
offers any hope of benefiting the patient. I do not hes- 




Fig. 41. — Winternitz's Psychrophor, or Cooling Sound. 

itate, however, to use in the following manner a solution 
of silver of a strength of sixty grains to the ounce. The 
caput is first fully exposed by the endoscope, then its 
surface is freely swabbed with the solution. Even after 
this application a few drops of blood will often follow 
the act of urination, and the tenesmus for the first few 
hours is often very severe. It is needless to say that 
this application should not be repeated until the reac- 
tion following the previous application has subsided. 

Seminal vesiculitis and spermatorrhoea (true and false), 
which so frequently complicate these long-standing 
cases of chronic posterior urethritis, are so far-reaching 
in their effects, and withal so important, that they de- 
serve separate consideration, and for that reason will not 
be touched upon in the present chapter. 



CHAPTER XYII. 

COWPERITIS. 

A resume of the diseases of the urethra would be in- 
complete without a brief description of the most com- 
mon complications that are met with as a result of the 
extension of the gonorrhoeal process along the ducts that 
open into the urethra. The extension of the gonor- 
rhoeal process, and its perpetuation, in the glands of 
Littre and urethral lacunae has already been dwelt upon 
in the chapters on the pathology and treatment of 
chronic urethritis, and will not enter into the present 
discussion, which will be confined to the inflammations 
of the glands of Cowper, the prostatic glands, the epi- 
didymis, and the seminal vesicles. 

The Glands of Cowper. 

These glands are often ignored by writers on urethral 
diseases, and when mentioned they are usually treated in 
such a manner as to lead one to form the erroneous im- 
pression that, except for the acute inflammations to 
which they are subject, they do not form a factor in the 
diseases of the urethra. 

The anatomy of these glands, according to Quain, is 
as follows : " In the bulbous portion of the urethra, near 
its anterior end, are the two openings of the ducts of 
Cowper's glands. These small glandular bodies (Fig. 34) 



144 



DISEASES OF THE URETHRA. 



are seated above the bulb, behind the membranous por- 
tion of the urethra, between the two layers of the sub- 
pubic fascia, the anterior layer supporting them against 
the urethra. The arteries of the bulb pass above, and 
the transverse fibres of the compressor urethrae beneath 
these glands. They are two small, firm, rounded masses, 
about the size of -peas, and of a deep yellow color. They 




Fig. 42. — Diagrammatic Representation of Cowper's Glands, the Prostatic 
Glands, the Utricle, the Seminal Vesicles, and Epididymis. 



are compound racemose glands, composed of several 
small lobules held together by a firm investment. This 
latter, as well as the walls of the ducts, contains muscu- 
lar tissue. The epithelium of the acini consists of clear 
columnar cells, with a reticular protoplasm, staining like 
the cells of mucous glands. The ducts are lined with 
cubical epithelium. The ducts unite outside each gland 
to form a single excretory duct. These ducts run for- 
ward near each other for about an inch or an inch and a 



COWPERITIS. 145 

half, first in the spongy substance and then beneath the 
mucous membrane, and terminate in the floor of the bul- 
bous part of the urethra by two minute orifices opening 
obliquely." 

Cowper's glands secrete a viscid fluid, which may serve 
the purpose of lubricating the urethra, but as they ap- 
pear to diminish in size in old age, and as they are 
analogous to the glands, of Bartholin in the female it is 
probable that their function is closely related to the sex- 
ual act. This hypothesis is supported by the anatomi- 
cal situation of the glands. It will be seen that they lie 
(Fig. 42) between the bulb and the urethra, and are sur- 
rounded by the fibres of the ejaculator urinse in such a 
manner that they would be compressed in the act of 
ejaculation ; besides, the lobules and ducts are endowed 
with muscular tissue, from which we may infer that the 
glands may have ejaculatory properties of their own. 

Acute inflammation of Cowper's glands is almost inva- 
riably due to an extension of a gonorrhoea from the ure- 
thra along the ducts of the gland, it therefore does not 
occur until the gonorrhoea has invaded the bulbous por- 
tion of the urethra, or usually not until two weeks after 
the inception of the disease. It may, of course, appear 
at any period subsequent to this, and in exceptional 
cases earlier, if the gonorrhoea has been unusually rapid 
in its progress along the urethra. 

With the onset of the disease there is usually felt a 
deep, stinging, or boring pain in the perineum, and on ex- 
amination a slight swelling, which is painful on pressure, 
can be detected to the left or right of the median line. 
The inflammatory phenomena often never go beyond this 
point, and frequently the disease is so mild that it is 
overlooked, and its symptoms, if recognized, attributed 



146 DISEASES OF THE URETHRA. 

to other causes, such as a posterior urethritis. In other 
cases, however, the long, narrow duct of the gland be- 
comes occluded, and there is retention of the inflamma- 
tory secretion, which gives rise to the formation of an 
abscess, which gives the characteristic combination of 
symptoms of swelling, redness of the skin, fluctuation, 
and constitutional disturbance, to which may be added 
the obstructive symptoms resulting from pressure 
against the urethra, which may amount to total retention 
of the urine. 

If the abscess is allowed to pursue its own course, it 
opens at the point of least resistance, which is usually 
through the skin, or it may open into the urethra, and in 
rare cases it may follow the planes of fascia and open 
either anteriorly or posteriorly, infiltrating the scrotal, 
or perirectal tissues, as the case may be. 

The treatment is directed to the symptoms. If they 
are mild no special treatment is required and the disease 
is best left to pursue its own course. If the patient is 
annoyed by the pain he experiences he should be placed 
in the recumbent position, where this is practicable, and 
hot applications or leeches applied to the part. If pus is 
present, or even if there is a doubt about the matter, a 
small, narrow-bladed knife should be thrust into the most 
superficial part of the swelling, and if pus escapes it 
should be freely evacuated ; if pus is not discovered the 
puncture will usually relieve the pain and often abort 
the inflammation. 

It is the opinion of the writer that the majority of the 
inflammations of Cowper's glands are, from the mildness 
of their symptoms, undetected, and that many of them 
lapse into a chronic inflammation that gives rise to a 
most intractable urethral discharg-e. It will be fre- 



COWPERITIS. 147 

quently noticed, on examining a case of chronic ure- 
thritis, that the moment the distal extremity of the endo- 
scope is withdrawn from the membranous into the bul- 
bous urethra, and has exposed that part, in which lie the 
orifices of the ducts of Cowper's glands, a drop of pus 
will suddenly appear in the endoscopic field. This has 
happened so often to the writer when examining- this sit- 
uation that he is forced to the conviction that there is a 
direct relationship between the pus and the glands of 
Cowper. It may be contended that the pus observed 
may be merely the urethral secretion that has accumu- 
lated in the bulbous urethra, but the same phenomena 
will appear if the patient has just urinated and cleansed 
his urethra of all secretion, and in exceptional cases will 
appear when the urethra, as far as an endoscopic exami- 
nation can determine, is in a healthy condition. 

While considering this subject we may digress far 
enough to inquire if the discharge from a chronic Cow- 
peritis may not in exceptional instances be mistaken for 
a prostatorrhcea. When we consider that the glands in 
health secrete a viscid secretion which is poured into 
the urethra during ejaculation, or when squeezed by the 
compressor urethra in the act of expelling the last drops 
of urine, we may readily conceive if there is a hypersecre- 
tion of this fluid that it may be mistaken for a prostatic 
discharge. The writer has seen such a case where the 
patient was supposed to have, and had the symptoms of, 
a prostatorrhcea ; but an examination revealed an appar- 
ently healthy prostate and an escape from the ducts of 
Cowper's glands of a profuse semipurulent viscid secre- 
tion. 

The treatment of a chronic Cowperitis without an 
appreciable swelling, and without pain or tenderness, is, 



148 DISEASES OF THE URETHRA. 

unfortunately, on account of its situation, almost beyond 
our reach. Some writers on urethral endoscopy claim to 
be able to make applications within the opening's of the 
urethral lacunae and the ducts of Cowper's glands ; to 
such the local treatment of the glands may prove effica- 
cious, but the writer has never been able to attain the 
necessary degree of skill in endoscopy to accomplish this, 
nor has he ever been fortunate enough to see it done, 
and is therefore forced to rely on less modern methods 
of treatment, such as the dilatation of the urethra with 
steel sounds and local applications of nitrate of silver to 
the urethra in the neighborhood of the orifices of the 
glands. 

In conclusion, it should not be forgotten that the exist- 
ence of a chronic Cowperitis may sometimes explain the 
obstinacy of a chroDic urethral discharge. 



CHAPTER XVni. 

THE ANATOMY OF THE EPIDIDYMIS AND SEMINAL 
VESICLES. 



The epididymis, from its peculiar formation, suffers 
most severely from the invasion of the gonorrhceal in- 
flammation. It consists of a convo- 
luted tube about twenty feet in length, 
which is coiled up in the most com- 
plicated flexuosities (Fig. 43). The ca- 
nal of the tube which forms the epidid- 
ymis varies in size from one-ninetieth 
to one-seventieth of an inch, but near 
its junction with the vas deferens it be- 
comes considerably larger. It is lined 
with columnar ciliated epithelium 
which tends to propel the secretions 
toward the vas deferens. The epididy- 
mis is attached to the posterior part of 
the testicle, and at its upper portion, 
where its tubular prolongations become 
continuous with the testicle, it is considerably enlarged, 
forming what is called the globus major or head of 
the epididymis. The epididymis then descends, and 
at the lower part of the testicle it abruptly turns up- 
ward to become continuous with the vas deferens. The 
lower part of the epididymis is slightly enlarged and 
is called the globus minor or tail, the intervening por- 




PiG. 43.— Plan of a 
Vertical Section of 
the Testicle, show- 
ing the Arrange- 
ment of the Ducts. 
(Quain.) 



150 



DISEASES OF THE URETHRA. 



tion between the head and tail is called the body of the 
epididymis. 

The vas deferens is the continuation of the canal of the 
epididymis. It passes upward to reach the inguinal 
canal, through which channel it enters the abdominal 
cavity, keeping under the peritoneum it reaches the base 
of the bladder and terminates, by its junction with the 
seminal vesicle in the common seminal or ejaculatory duct. 
The vas deferens is about two feet in length and has a 
diameter of about one-tenth of an inch, but becomes 
slightly enlarged at the base of the bladder, where it 
resembles the seminal vesicle, and then becomes nar- 
rowed before it joins its accompanying seminal vesicle. 

The epithelium of 
the vas deferens is 
of the columnar 
kind, but, unlike 
the epithelium of 
the canal of the 
epididymis, it is 
devoid of cilia. 

The seminal ves- 
icles (Fig. 44) are 
t w o membranous 
receptacles situ- 
ated between the 
base of the blad- 
der and the rec- 
tum, and lying ex- 
ternal to the vas 
deferens. Each 
vesicle consists of a tube about two inches in length and 
half an inch in width at its widest part. When this tube 




Fig. 44.— Base of the Male Bladder with the 
Vesiculae Seminal*, Vas deferentia, and 
Prostate Gland Exposed. (From Haller.) 



THE ANATOMY OF THE EPIDIDYMIS. 151 

is unravelled, however, it is seen to consist of an irregu- 
lar tube about six inches in length, which has been 
reduced to two by its numerous flexures and coils. 

At its junction Avith the vas deferens it becomes 
straight and narrow, and joins with the latter at an acute 
angle. 

The united vas deferens and seminal vesicle forms the 
ejaculatory duct, which passes forward between the middle 
and lateral lobes of the prostate gland, to terminate on 
the floor of the prostatic urethra in a minute opening, on 
the lateral portion of the anterior aspect of the caput 
gallinaginis. 

The seminal vesicles serve as a pouch for the reception 
of the seminal fluid, and there are good reasons for 
believing that it is in the seminal vesicles that the sper- 
matozoa mature : it has been noticed after frequent inter- 
course, that the spermatozoa are not completely formed, 
probably on account of their remaining but for a brief 
time in the vesicles. The seminal vesicle has also a 
secretion of its own, which is ejaculated with the sem- 
inal fluid, and seems essential to the virility of the latter. 
It is endowed with muscular tissue which enables it, 
under the stimulus of the sexual orgasm, to suddenly 
and forcibly evacuate its contents. 



CHAPTER XIX. 

EPIDIDYMITIS. 

Inflammation of the epididymis is, in nearly every 
case, secondary to the gonorrhceal process in the deep 
urethra, and is supposed to be due to the transference 
of the infective secretion from the posterior urethra, 
along- the ejaculatory duct and vas deferens to the con- 
voluted tube which forms the epididymis. The metas- 
tatic theory of infection is scarcely tenable, but it is not 
always easy to explain on other grounds the rapid infec- 
tion of the epididymis which we sometimes witness as 
the result of some exciting cause in the progress of a gon- 
orrhoea, such as the passage of a sound, the use of injec- 
tions, exercise on a bicycle or on horseback, or sitting on 
a stone seat, any of which may be followed by the onset 
of epididymitis which usually manifests itself within a 
few hours, or, at most, on the following morning. The 
rapid onset of the inflammation in these cases can 
scarcely be attributed to the extension of the inflamma- 
tory process along the entire length of the vas deferens, 
when we consider the vas deferens is about two feet in 
length, and that it takes the same process fully one week 
to travel from the meatus to the posterior urethra. It 
may be possible, but it is highly improbable, that the 
micro-organisms of the disease have in these cases 
already extended to the epididymis, and only await a 



EPIDIDYMITIS. 153 

favorable exciting- cause, such as has been mentioned, to 
become aggressive. It must be admitted that these 
explanations are unscientific, but they are the best we can 
offer, and in the absence of a more satisfactory solution of 
the question it must be left in this unsettled condition. 
It may be asked: Is an epididymitis always the result 
of a gonorrhoea? May it not appear independently of 
a gonorrhoea? May its presence not infrequently be a 
coincidence rather than a sequel of a gonorrhoea? An 
affirmative answer to these questions cannot be denied, 
but such an occurrence must be so exceptional that we 
need not consider the claim of a gonorrhceal parentage 
invalidated by it, and we are therefore justified in clas- 
sifying an epididymitis among its numerous unhealthy 
progeny. Even in those rare cases where an epididymitis 
exists without any visible evidence of the existence of a 
urethritis, it should not be forgotten that a mild pos- 
terior urethritis may be present without any evidence of a 
urethral discharge other than is manifested by a careful 
examination of the urine. 

It was formerly supposed that the left epididymis was 
affected more frequently than the right, but statistics 
show that the difference is so slight that it may be ig- 
nored. It is rare for the epididymis on both sides to be 
affected at the same time, and when such does occur there 
are grave dangers of impotence following from occlusion 
of both of the vas deferens. 

The onset of an epididymitis is exceedingly rare before 
the termination of the first week of a gonorrhoea, and the 
majority of the cases occur between the second and fifth 
week of the disease. The following statistics from the 
cases collected by Fournier, Le Fort, Gaussaille, De Es- 
pine, Aubrey, Castelnau, and Unterberger (quoted from 



154 DISEASES OF THE URETHRA. 

Finger), give the results regarding the period of onset of 
epididymitis : 

1 week after iuf ection in 46 cases. 

2 weeks after infection in 157 " 

3 * " 132 " 

4 " " " " 191 " 

5 " " "' " 132 " 

6 ' " 64 " 

7 " " " " 44 " 

8 " " " " 61 " 

3 months after infection in 66 " 

4 ' " 33 " 

5 " " " " 18 " 

6 " " " " 22 " 

7 " " " "._ 9 " 

8 ' " 8 " 

9 " " " " 5 " 

10 to 12 years after infection in 8 " 

2 " " " " 9 « 

3 " " " " 7 " 

4 " " «• " 2 " 

7 " " " " '. 1 case. 

1,015 cases. 

Symptoms The symptoms of epididymitis vary accord- 
ing- to the severity of the inflammation, and we may rec- 
ognize, if we wish, the subacute, the acute, and the hyper- 
acute, hut this distinction is artificial and for our purpose 
unnecessary. The milder forms of the disease may be as- 
sociated with but little else than an aching and slight swel- 
ling of the epididymis, which is often localized to the head 
of the organ. In these cases there is an absence of con- 
stitutional symptoms, and the patient is usually able to 
pursue his ordinary occupation. These cases of mild or 
sub-acute epididymis are more often seen in the recur- 
ring type of the disease than in the primary attack 
which follows acute gonorrhoea, in which the onset of the 
disease is usually associated with severe constitutional 



EPIDIDYMITIS. 155 

disturbance which is often so severe as to prostrate the 
patient. In severe cases the epididymis becomes quite 
hard and swollen, the enlargement is as a rule first no- 
ticed in the head of the epididymis, then extends to the 
tail, after which the vas deferens may become thickened 
and tender, this progression is contrary to what we 
would expect when we consider the course which the dis- 
ease is supposed to travel, but it may be due to the fact 
that the convolutions of the tube are more numerous in 
the head of the epididymis than elsewhere, and therefore 
an inflammatory swelling is sooner manifested at this 
place. The epididymis sometimes become swollen to an 
enormous size when we consider its insignificance in 
health, and when the testicle becomes involved the swell- 
ing of both may form a tumor as large as the fist. In 
severe cases the overlying scrotal tissues become inflamed 
and cedematous, and the tunica vaginalis may be distended 
with fluid (acute hydrocele). There is a type of this dis- 
ease, fortunately rarely met with, in which the symptoms 
are alarming, and in some cases, especially if the patient 
has been debilitated by previous illness, may seriously en- 
danger the patient's life, even fatal results have ensued. 
In these cases the disease is ushered in with a severe 
chill. The temperature may run up from 103° F. to 105° 
F., and the pulse range from 100 to 150. Vomiting may be 
severe and persistent, and the symptoms of strangulation 
of the intestine may be closely simulated ■ the simile may 
be almost complete if we find the inguinal canal occupied 
by a very much swollen and a very tender vas deferens. 
The operation for strangulated hernia has been under- 
taken for such a case as has just been described. 

There is a troublesome variety of epididymitis which 
may be called the recurring variety. In these cases the 



156 DISEASES OF THE URETHRA. 

inflammation is seldom severe, if we leave out of consid- 
eration the primary attack, but there is a tendency, as 
the name indicates, for the disease to return on the 
slightest provocation. Some of these patients are almost 
invalided by the disease, as they are scarcely free from 
one attack before the onset of another. Even when there 
is no visible discharge from the urethra, and when the 
patient considers himself free from urethral inflammation 
he may be pestered by the recurring epididymitis. It will 
usually be found, however, that the freedom from ure- 
thral disease is more fancied than real, for an examina- 
tion of the urine will usually show the presence of pus 
and epithelial threads, and the passage of the sound will 
often reveal an abnormal tenderness of the posterior 
urethra ; nor will these attacks in all probability cease 
until the posterior urethra has been restored to a healthy 
condition. 

In some cases of acute epididymitis, more especially if 
the testicle is also involved, the inflammation terminates 
in the formation of an abscess which either ruptures ex- 
ternally or is opened by the surgeon. From these ab- 
scesses a curdy pus is evacuated, in which broken-down 
tubules and glandular tissue is found. These abscesses 
are prone to leave persistent indurated sinuses which 
continue for a long time to discharge a little curdy pus. 

One of the most unfortunate sequelae of epididymitis is 
atrophy of the testicle from blocking of the duct of exit. 
This is usually found in the vas deferens near the epidid- 
ymis, and may follow from a slight degree of inflamma- 
tion, but the liability to its occurrence is proportional to 
the severity of the inflammation. As in most double or- 
gans the function may continue when one organ is de- 
stroyed, so also in the testicles, if one of them is de- 



EPIDIDYMITIS. 157 

stroyed impotence is not produced. In cases of double 
epididymitis, however, a guarded prognosis should be 
given regarding the further usefulness of these organs. 

A peculiar symptom, which has not been satisfactori- 
ly explained, and which has been used to bolster up the 
theory of the metastatic cause of epididymitis, is the 
marked decrease in the urethral suppuration which fol- 
lows the onset of an epididymitis. This symptom is of- 
ten most pronounced: for example, in the evening the 
urethra may be discharging most profusely, and in the 
morning it may have disappeared, but is replaced by that 
peculiar sickening pain, so characteristic of epididymitis, 
which makes the patient feel that in escaping from his 
urethritis he has fallen out of the frying-pan into the fire. 
It seems useless to attempt to explain this phenomena, 
as one theory can be met with a counter-theory equally 
as good, and we may add equally as unsatisfactory, so 
we are forced to content ourselves with the recognition 
of the clinical fact and to leave this enigma for the pres- 
ent unsolved. It should be noted that with the subsi- 
dence of the epididymitis there is usually an increase in 
the urethral discharge. 

Treatment. — The treatment of epididymitis, while all- 
important, will be dwelt upon but briefly. The heroic 
methods of treatment, which have been recommended, 
such as the application of the actual cautery to the in- 
flamed part, and puncture of the tunica albuginea, had 
perhaps better be reserved for hospital cases, as but few 
patients will be found willing to submit to such treat- 
ment, and we should resort, preferably, to the more lenient 
but time-honored remedies. In the acute stage of the 
disease there is nothing better than heat or cold, the 
former being applied by means of a poultice, which should 



158 DISEASES OF THE URETHRA. 

be large enough to surround the entire scrotum, and warm 
enough to make the patient flinch when first applied. It 
has been the custom, and it seems to be a good one, to 
strew the surface that is applied to the scrotum with a 
thin layer of common cut tobacco, and to continue this 
application until the patient is slightly nauseated. It is 
hard to imagine that this point will be easily reached in 
those accustomed to the use of tobacco, in whom it is 
probably less efficacious than in those who are not to- 
bacco habitues. 

Cold applications are, as a rule, less efficacious and less 
agreeable to the patient than hot, and many cases will 
not tolerate them. In other cases it is the remedy par ex- 
cellence, but unfortunately I know of no criterion by 
which we may judge of the cases for which it is best 
adapted. If cold is applied it should be in the form of 
the ordinary lead-water and opium solution. Cracked ice 
is difficult to apply, and the intensity of the cold is, to 
say the least, painful. 

In the acute stage of the disease it is all-important that 
the patient be kept in the recumbent position. This is 
much more important than internal medication, which is 
usually disappointing and in most cases may well be 
ignored, unless it should be necessary to regulate the 
bowels or relieve pain, if the latter is intense. 

After the acute stage has passed nothing is so comfort- 
ing and hastens resolution so quickly as uniform press- 
ure, but unfortunately the testicles are so movable that 
this is not easy to apply. A good tight-fitting suspen- 
sory, such as the Army and Navy bandage, is about the 
easiest to apply, but it does not as a rule reduce the swell- 
ing so quickly as strapping the testicle, which has the 
added advantage of the retention of the heat and moist- 



EPIDIDYMITIS. 159 

ure of the part by the use of the impervious adhesive 
plaster. The proper application of the adhesive strap- 
ping to the testicle is an art which can only be acquired 
by experience. Full directions for this can readily be 
obtained from almost any of the works on surgery, and it 
therefore need not be entered into here, but the novice 
should be warned,, in order to avoid disappointment, that 
his completed work will probably bear but little resem- 
blance to the cuts one sees of it, for the original of some 
of the graceful cuts of strapped testicles must have 
existed solely in the mind of the artist who made them. 

It is necessary to renew the strapping whenever the 
testicle shrinks so much that the strapping becomes 
loose. 

In some cases of epididymitis an indurated painful 
nodule will remain in some part of the epididymis to tor- 
ment both patient and physician. These painful indura- 
tions are most obstinate to treatment, but in time will 
wear away. Iodine, either internally in the form of iodide 
of potassium, or iodine ointment applied over the indura- 
tion, seems most efficacious in these cases. If this treat- 
ment fails, massage may be tried if the induration is not 
too painful. 

In those unfortunate cases where atrophy of the testi- 
cles follows as the result of destruction of the lumen of 
the vas deferens, there is but little treatment to be 
adopted further than the cultivation of a spirit of resigna- 
tion. We may, however, in selected cases, excise the 
obliterated portion of the vas deferens and suture the 
severed ends together. This has been successfully ac- 
complished and may offer a ray of hope in an otherwise 
hopeless case. 

After the recovery from an attack of epididymitis the 



160 DISEASES OF THE URETHRA. 

patient should continue to wear a suspensory bandage 
for at least a month, and longer, if, in the meantime, his 
urethritis has not recovered. 

Perhaps the most important treatment in relation to 
this subject is the prophylactic treatment. To prevent 
the disease is infinitely better than to cure it, and much 
may be done in this line by the wearing- of a suspensory 
bandage during the course of a urethritis, by the discrim- 
inating use of injections, in fact by any precaution or 
treatment that will tend to prevent the extension to the 
posterior urethra of the gonorrhoeal process. 



CHAPTEK XX. 

ACUTE SEMINAL VESICULITIS. 

Acute seminal vesiculitis is, almost without exception, 
like acute epididymitis, a result of the extension of the 
gonorrheal process to the deep urethra, from which it 
extends, along- the ejaculatory duct, to the seminal vesi- 
cle. Many of the symptoms of this affection correspond 
very closely with some of the symptoms of acute poste- 
rior urethritis, and on this account it is probable that its 
presence is often overlooked, especially as a positive 
diagnosis can only be made by a rectal examination. 
We know the frequency with which the gonorrheal 
inflammation extends to the epididymis ; and in doing 
so, if we accept the theory of infection by extension of 
the gonorrhea along the ejaculatory ducts and vas defer- 
ens, there seems to be no good anatomical reason why 
it should not extend with equal facility to the seminal 
vesicles. A more careful observation on this point will 
probably demonstrate that acute seminal vesiculitis is at 
least as frequent as acute epididymitis. 

Acute seminal vesiculitis is often masked by its asso- 
ciation with acute posterior urethritis, but if we will, for 
our purpose, isolate these affections, it will be found that 
acute vesiculitis is characterized by a burning, tense feel- 
ing, felt deep in the perineum ; along with this there will 
be an irritable condition of the bladder, frequent and pain- 
ful micturition, and a disagreeable sensation in the rec- 
11 



162 DISEASES OF THE URETHRA. 

turn, which is aggravated by the accumulation of faeces 
or by the movement of the bowels. 

The sexual organs are usually in an easily excited con- 
dition ; pollutions are frequent and painful ; the ejacu- 
lated fluid is usually very abundant, and in some cases 
may be bloody, but more often is yellowish from the pres- 
ence of pus, and leaves a stain on the linen. 

There may be severe constitutional symptoms, partic- 
ularly if there is an obstruction of the excretory duct and 
retention within the vesicle of the inflammatory prod- 
ucts. 

A rectal examination reveals a hot, tender, and swollen 
vesicle, and the prostate gland will often be found in a 
similar condition. When both vesicles are involved they 
may apparently coalesce in the median line and form a 
swelling of considerable dimensions. 

This disease usually ends in resolution in from one to 
two weeks, but in a small percentage of the cases the 
disease assumes a chronic form, and in rare cases an ab- 
scess forms from the obstruction of the duct of exit. 
The treatment varies but little from that of acute pros- 
tatitis, and consists in the maintenance of the recumbent 
position, and also in the use of hot-water injections into 
the rectum, or by the local application of cold, which is 
accomplished by the insertion of a piece of ice just 
within the grasp of the sphincter ani. The bowels 
should be regulated, and the accumulation of faeces 
within the rectum avoided. When suppuration of the 
vesicle takes place the pus should be evacuated as soon 
as possible, for if left to itself it may rupture in an un- 
favorable situation and may infiltrate the subperitoneal 
tissues, or even empty itself into the general peritoneal 
cavity. It is advisable to evacuate the pus through an 



ACUTE SEMINAL VESICULITIS. 163 

incision carried transversely between the bulb of the 
urethra and the anus, the dissection should be carried 
parallel to the rectum, a finger being kept within the lat- 
ter to act as a guide and to prevent the wounding of the 
rectum. In some cases the abscess may be advantage- 
ously evacuated by an aspirator inserted through the 
wall of the rectum, and the cavity, as soon as the pus is 
evacuated, washed out, by means of the same instrument, 
with an antiseptic solution. 



CHAPTER XXI. 

CHRONIC VESICULITIS AND FOLLICULAR PROSTATI- 
TIS. 

This is a complex subject to deal with because it in- 
volves the consideration not only of the phenomena 
directly dependent on the pathological condition of the 
vesicles and prostatic glands, but also, to a perhaps still 
greater degree, the consideration of the peculiar mental 
phenomena engendered by this condition, to which the 
name genito-urinary neurosis has been given. Nor can 
this subject be intelligently discussed separately or with- 
out taking' into consideration the morbid conditions that 
are usually present at the same time in the adjacent 
structures, namely, the utricle and caput gallinaginis, as 
well as in the mucous membrane of the posterior ure- 
thra, the whole being endowed with a very sensitive 
and very highly organized nervous supply (page 120), 
which renders it peculiarly susceptible to the impres- 
sions its morbid condition engenders, and which, in its 
turn, by acting on the general nervous system, produces 
that neurotic and neurasthenic condition these cases so 
frequently exhibit. 

We have long known the baneful effects on the nervous 
system of women produced by chronic inflammation of 
the uterine mucous membrane, and we have also seen 
(page 118) the analogy of the uterus and the parts under 
discussion not only in development but also in nervous 



CHRONIC VESICULITIS. 165 

supply, therefore it is not difficult to appreciate the rea- 
son for the almost hysterical manifestations that some 
of these cases of catarrhal affections of the deep urethra 
and its diverticula present. 

It is unnecessary to enter into a dissertation on the 
peculiar neuropathic conditions which we find to hold a 
prominent place in the symptomatology of this disease, 
as such is best reserved for works on nervous diseases ; 
suffice it for our purpose to recognize the existence of 
such conditions and their frequent dependence on the 
presence of some long-standing morbid condition of 
highly organized structures such as are at present un- 
der consideration. 

It will be necessary, however, before entering into the 
subject before us, to define one of the most prominent 
symptoms Ave will meet with, namely, spermatorrhoea. 
Spermatorrhoea is divided into the true and false. True 
spermatorrhoea consists in the loss, of seminal fluid at 
abnormal times ; that is, at times when sexual excite- 
ment is absent or not sufficiently intense to produce an 
orgasm. False spermatorrhoea is the loss of fluid re- 
sembling semen, which usually escapes from the urethra 
after defecation and sometimes after urination. It 
should not be forgotten, however, that these two affec- 
tions may coexist, and in false spermatorrhoea a few 
spermatozoa may be present in the discharge. 

It will also be understood that unless special refer- 
ence is made, the glands of the prostate and the semi- 
nal vesicles are considered together. 

Chronic inflammation of the seminal vesicles and pros- 
tatic glands is produced by the same causes to which 
chronic posterior urethritis owes its origin. Unquestion- 
ably one of the most potent factors is the extension of 



166 DISEASES OF THE URETHRA. 

the gonorrhoeal process, which may at first produce acute 
prostatic folliculitis and acute seminal vesiculitis ; but 
there are undoubtedly many of these cases that should 
be classed among- the subacute or chronic from their be- 
ginning, just as there are cases of gonorrhoeal posterior 
urethritis that are so mild in their inception that they 
should be excluded from the acute form of the disease. 

Disturbances in the sexual functions, notably mastur- 
bation and ungratified sexual desires, play a no less po- 
tential part in the production of chronic vesiculitis and 
follicular prostatitis. To these may be added excessive 
sexual indulgence, and in all probability sedentary hab- 
its, the rheumatic or lithaemic diathesis, if not exciting- 
causes, at least predispose to its production. 

The pathology of the disease is simply that of catar- 
rhal inflammation of the lining membrane of the pros- 
tatic glands and seminal vesicle, with the development in 
long-standing cases of periglandular connective tissue 
and consequent fibroid changes. The prostate in the 
early stage is swollen and tender, and its surface is nodu- 
lar from the formation of minute retention cysts as the 
result of the blocking of the orifice of the glands. Later 
there may be atrophy of the prostate from the develop- 
ment and contraction of the periglandular tissue, which in 
time may obliterate the glands and by this process effect 
a cure of the local inflammatory trouble. The seminal 
vesicle will also be found to be swollen and thickened 
from the development of fibroid tissue. 

The symptoms are somewhat complex when we take 
into consideration the neurotic phenomena almost always 
associated with this disease. The patients are liable, to 
be depressed at trifles, there is often a want of energy 
and a degree of lassitude that cannot be accounted for 



CHRONIC VESICULITIS. 167 

by any defect in the patients' general health, for, as a rule, 
these patients look to be in fairly good condition, al- 
though they often suffer from d} 7 spepsia and lith&mia- 
Many of these patients are hypochondriacal to an ex- 
treme degree, and seem to take a delight in magnifying 
their ailments, and will innocently ask their physician if 
there ever was a case as bad as theirs. 

In some cases neurasthenic symptoms predominate 
and the patients will make their bodily and mental 
fatigue the burden of their complaints. In others there 
is a lack of fixation of the will-power, they will take up 
some task with their usual energy, but in a short time it 
palls upon them and it is with difficulty that they can fix 
their attention on the work before them. A lack of mem- 
ory is also often met with. It will readily be seen that 
these patients form good picking for the vultures that 
hang on the outskirts of our profession and gain an in- 
famous livelihood by preying on the fears of their pa- 
tients. Let one of them pick up a newspaper and read 
the glaring advertisements about lost manhood, insanity, 
etc., and unless he is more sensible than the average of 
these cases he is likely to be anything but benefited by 
the perusal of such literature. 

The symptoms which distress these patients the most 
refer to the sexual functions. Early in the disease 
the sexual organs are abnormally excitable and pollu- 
tions are frequent. Sexual congress is usually unsatis- 
factory, owing to a premature emission as a result of the 
hyperoesthetic condition of the posterior urethra, espe- 
cially of the caput gallmaginis. There is usually but- 
little sensation in the act, although sometimes a sharp 
pain is experienced at the moment of ejaculation if the 
vesicles are very tender, or, if there is a stenosis of the 



168 DISEASES OF THE URETHRA. 

ejaculatory ducts, which may be caused by a swelling of 
the mucous membrane or a narrowing from the encroach- 
ment of the surrounding interstitial tissue. In other 
cases there is a more or less degree of impotence, 
produced either by a lack of sexual desire or an inabil- 
ity to produce an erection, and the patients will often 
complain that the penis is cold and shrivelled up. In 
some cases there is an escape of glairy fluid which has a 
seminal odor, and in which the microscope demonstrates 
the presence of numerous spermatozoa ; this fluid may 
escape under the stimulus of sexual excitement or even 
without such stimulus, and the patient will be conscious 
of it trickling from the meatus. Sometimes it only 
appears after straining at stool or after urination. In 
other cases, and these are the most common, the fluid 
resembles semen in appearance and odor, but contains 
few or no spermatozoa, which, when present, are usually 
lifeless. This fluid is expressed from the seminal ves- 
icles or the prostatic glands, or both together ; it is thin- 
ner than normal semen, and is less readily coagulable. 

It is rarely seen except during defecation or after the 
act of urination, being extruded by the contraction of the 
levator ani and detrusor muscles of the bladder. 

As the seminal vesicle is normally a receptacle for its 
own secretion, and probably that of the testicle also, we 
must presume that when its contents escape at abnormal 
times there is either an excessive secretion or a patulous 
condition of its excretory duct. It is probable that in 
vesiculitis both these conditions exist at the same time. 

Ultzmann lays considerable stress on the diagnostic 
value of the presence of spermatic crystals in determi- 
ning the source of these discharges. These crystals are 
colorless, transparent, rhomboid bodies (Fig. 45), and 



CHRONIC VESICULITIS. 



169 




Fig. 45.— Spermatic Crystals. 800 Diameters. 
(Ultzmann. ) 



the method of examining- for them is as follows : The 
suspected fluid is placed on a glass slide and permitted 
to dry in the open 
air, and then exam- 
ined at intervals. 
If the fluid is ex- 
clusively from the 
prostatic glands no 
spermatic crystals 
will appear. If it 
is normal semen 
the crystals will 
not only be scant, 
but will also be 
late in making 
their appearance, 
perhaps not for 
one or two days. On the other hand, if the fluid is vesi- 
cular, and such as we see in vesiculitis, the crystals will 
appear early, probably in half an hour, and as time goes 
on they will be found in great abundance. These crystals 
belong essentially to the secretion of the seminal vesicles 
and are therefore of considerable diagnostic importance. 

The treatment of these cases, as may be readily con- 
jectured, is a matter of difficulty and uncertainty, and a 
guarded prognosis should always be given, for it not 
infrequently happens that the case, in spite of all treat- 
ment, remains unchanged, although in most cases a 
marked improvement or a cure can be effected. 

It is important that the neurotic symptoms should be 
combated, and the groundless fears which the patient 
usually entertains dispelled. All irregular habits that 
may be productive of this disease should be corrected. 



170 DISEASES OF THE URETHRA. 

If there is dyspepsia or lithsemia present they should be 
attended to, and the patient's general health brought to 
the best possible condition. A sea voyage, or an entire 
rest from active duties, will often be productive of mark- 
edly beneficial results. Aside from the general treat- 
ment internal medication directed to the diseased parts 
will often be beneficial, but should be used with dis- 
crimination. If there is a very excitable condition of 
the sexual organs, bromide of potassium seems to be the 
most efficacious, and lupulin, camphor, and hyoscyamus 
are sometimes useful. In the advanced atonic stage, 
associated with diminished sexual excitability, strychnia, 
iron, and phosphide of zinc may be tried. 

Locally, electricity has been employed with benefit, 
but it should be used very cautiously, and only weak 
currents employed at first. The galvanic current may 
be used by applying a urethral electrode, attached to 
the negative pole, to the deep urethra ; the positive 
electrode being applied to the perineum. The faradic 
current may be employed by applying the anode over 
the perineum and the cathode within the rectum. 

The most efficacious treatment seems to be the intro- ' 
duction of large, cold sounds within the deep urethra, 
and maintaining them in situ for about five minutes. 
This treatment should be repeated about every second or 
third day. Winternitz's cooling sound (Fig. 41) is also 
a very useful agent in the treatment of this disease. 

If there is at the same time a catarrhal condition of 
the posterior urethra present, it should be treated ac- 
cording to the method recommended in Chapter XVI.; 
in fact, the treatment recommended for posterior ure- 
thritis resembles, or is almost identical with, the treat- 
ment recommended above. Fuller, of New York, has 



CHRONIC VESICULITIS. 171 

written a wOrk on seminal vesiculitis, in which he claims 
to have obtained good results from stripping or milking 
the seminal vesicles. The method he adopts is to have 
the patient bend forward so that his body and legs are at 
right angles, and with the finger express the contents of 
the seminal vesicles by a stripping motion. This treat- 
ment may possibly be efficacious, but it is a little difficult 
to understand its therapeutic action, and it would seem to 
be a difficult matter to reach with the finger the distal 
extremity of the vesicle. 



CHAPTER XXII. 
STRICTURE OF THE URETHRA. 

Anatomy. 

The urethra in a state of quiescence is a closed canal, 
its mucous surface being- retained in apposition by the 
elasticity and contractility of the connective and mus- 




Fig. 48.— Diagram of the Forcibly Distended Urethra. 

cular tissues which invest it throughout its whole extent. 
It is only therefore when it is dilated, as during urina- 
tion or instrumental interference, that a stricture is capa- 



STRICTURE OF THE URETHRA. 



173 




ble of demonstration. When the urethral canal is closed 
or at rest its lumen may be represented by a capillary 
tube which conforms to the curves of 
the urethra, as in Fig-. 46. It is self- 
evident that the lumen of the urethra, 
if a lumen can be said to exist un- 
der such circumstances, is uniform 
throughout, with the possible excep- 
tion of the portion comprising- the 
fossa navicularis where the urethral 
walls are seldom accurately coaptated. 
When the urethral walls are separated 
by intra-urethral distention, the ure- 
thra, as it were, unfolds itself and ex- 
erts a distending force on the peri- 
urethral tissues. Up to a limited 
degree of dilatation the urethra main- 
tains a uniformity in its calibre, but 
as the dilatation increases the varia- 
bility in certain portions of the ure- 
thra, not only of its own elasticity, 
but also of the resistance to displace- 
ment of the peri-urethral tissues, pro- 
duces a variation in its calibre which, 
at first scarcely recognizable, becomes, 
on further distention, very marked, as 
is shown in Fig. 47, and to a still 
greater extent in Fig. 48, where the 
distention is very great. A few years 
ago I devised a urethrograph (Fig. 49) Fig. 49.— The Urethro- 
for taking a diagram of the dimen- grap 1 - 

sions of the urethra. This instrument is so constructed 
that it will take a diagram of the dimensions of the 




174 



DISEASES OF THE URETHRA. 



whole urethra, under a uniform but adjustable degree 
of distention. The observations which I have made with 
the urethrograph have not shed a new light 
on the topography of the urethra, but have 
simply served to confirm the observations 
that anatomists have long since made, name- 
ly, that the distended urethra is a canal of 
variable diameter, no one part of which can 
be taken as a criterion of the dimensions of 
the other. Nor can one urethra be taken 
as the standard from which to judge others, 
so much do they differ from each other in 
their relative dimensions. Not only does 
the lumen of one urethra differ from that of 
another, but each urethra differs from itself 
according to the degree of distention it un- 
dergoes. This is well illustrated in the fol- 
lowing series of diagrams (Fig. 50), taken 
with the urethrograph from the same ure- 
thra under varying degrees of distention. 
The lines traced by the urethrograph do 
not represent the contour of the urethra; 
they only show the diameter of the urethra, 
at all points, in millimetres, measured from 
a straight base line. The first diagram, or 
the one nearest the base line, shows the ure- 
thra under a moderate degree of distention. 
The second, third, and fourth diagrams show 
the urethra under a progressively increased 
It will be noticed that the greater 



40 30 20 

degree of distention, 
the degree of distention the greater the deviation from 
uniformity of calibre ; and conversely, the less the degree 
of distention the more nearly uniform becomes the calibre 



STRICTURE OF THE URETHRA. 



175 



of the urethra. As the distending force exerted against 
the urethra by the urethrograph was certainly greater in 
the diagram nearest the base line than would be exerted 
by the passage of a stream of urine, the inference is fair 
that the urethra under a degree of pressure equivalent to 
that exerted by the passage of a stream of urine would 
conform more closely to a tube of uniform calibre. The 
chief points of interest which these diagrams bear to the 
subject of stricture are that the healthy urethra, as dis- 
tended by the passage of a stream of urine, is a canal of 
almost uniform dimensions, and that the same urethra 
under a degree of distention no greater than is habitually 
exerted by the passage of urethral instruments shows 
marked irregularities in its calibre. The calibre of the 
urethra is thus a fluctuating quantity, its variations de- 
pending on its degree of dilatation ; therefore no stand- 
ard can be given as accurately representative of the nor- 
mal urethra. 

Sir E. Home has given a cast of the normal urethra 
under forced dilatation 
which may be considered 
a fair representative of 
the over-dilated urethra 
(Fig. 51). 

In a memorable con- 
troversy between Dr. 
Sands and Dr. Otis on 
this subject, the former 
exhibited a series of casts 
of the urethra (Fig. 52) 
to illustrate its natural 
irregularities. Dr. Sands contended that these irregulari- 
ties were present in the healthy urethra, and were in no- 




PlG. 51. — Diagram of the Urethra Show- 
ing its Extensibility. (Sir E. Home. ) 



170 



DISEASES OF THE URETHRA. 



wise pathological. To this Dr. Otis replied that these 
irregularities were either of pathological formation, or, 
if not, would, by retarding the stream of urine, and thus 




Fig. 52. — Casts of the Male Urethra. (Sands.) 

creating a point of increased friction, be capable of per- 
petuating a urethral discharge. Since no evidence could 
be brought forward to prove the absence of a pre-exist- 
ing urethritis in the cases from which these casts were 
taken, the arguments put forward that the irregularities 
were pathological in formation could not be refuted, al- 
though the weight of evidence was against such being 
the case. In considering this subject it occurred to the 
writer that a series of casts of the infantile urethra would 
be representative of the urethra under conditions which 
would preclude the possibility of pathological irregulari- 
ties in its formation. The opportunity was therefore 
availed of to make a series of wax casts of the infantile 
urethra, cuts of which are given in Fig. 53. The first 
cast was taken from the urethra of an infant two weeks 



STRICTURE OF THE URETHRA. 



177 



old. The injection was made under water ; the wax was 
forced into the bladder until a stream issued from the 
meatus which was estimated to be equivalent in force to 
that of a stream of urine. In a few moments the stream 
of wax solidified, the bladder and the urethra were laid 
open, and the cast was extracted. The second cast was 
taken in the same manner from an infant two months old. 
The third and fourth casts were taken from infants aged 
six and nine months respectively. In the two latter cases 




Fig. 53. — Casts of the Infantile Urethra. 



the prepuce was surrounded by a ligature to prevent the 
escape of the injection, which was forced into the blad- 
der under a pressure almost sufficient to rupture that or- 
gan. In comparing these casts the fact already pointed 



178 DISEASES OF THE URETHRA. 

out is apparent, namely, that the calibre of the urethra 
depends on the degree of intra-urethral distention, being ap- 
proximately uniform if the distending force is slight; bat 
showing marked irregularities on forced distention, so that 
no one part can be taken as a criterion of the dimensions of 
another. 

It is an incontrovertible fact that a stricture may nar- 
row the stream of urine or occlude it entirely ; but in 
order to do this it is evident that it must, in the light of 
what has been said on the subject, be a well-defined strict- 
ure, and be capable of demonstration by instruments 
which do not dilate the urethra to a greater degree than 
is exerted by the passage of the stream of urine. We 
have seen that the over-dilated urethra exhibits well- 
marked points of contraction which are not perceptible 
under a degree of pressure equivalent to that exerted by 
the passage of a stream of urine. Therefore those con- 
strictions which are only elicited by over-dilatation of the 
urethra can in nowise be considered as acting as points 
of increased friction or of retarding the stream, and are 
as innocuous from this point of view as if they never had 
existed. Urethral coarctations which are insufficient to 
narrow the stream of urine are not strictures in the true 
sense of the word, and by some writers do not receive 
recognition. Sir Henry Thompson defines stricture as 
" a deposit of lymph around the canal of the urethra at 
some point, which, not permitting it to open to the press- 
ure of the stream of urine, narrows the current to a greater 
or less extent.'''' Taylor aptly says : " To my mind a canal 
may be said to be the seat of stricture when its calibre is 
reduced below that which nature requires it to be in the 
performance of its functions." The lumen of the male 
urethra is such a variable quantity that no definite size 



STRICTURE OF THE URETHRA. 179 

can be fixed as the one which would constitute the limit 
between a strictured and a non-strictured urethra. 

Since pathogenic properties have been attributed to 
even the slightest coarctations in the dilated urethra, 
their recognition is necessary. We may, therefore, di- 
vide strictures into two classes, the true and the false, or, 
in the generally accepted classification of strictures, of 
large and small calibre. Strictures of large calibre may he 
defined as those points of narrowing in the urethra which are 
not of sufficient extent to retard the flow or narrow the stream 
of urine. Strictures of small calibre are those points of nar- 
rowing in the urethra which are of sufficient extent to retard 
the flow or narrow the stream of urine. In referring to 
stricture of large or small calibre in the remainder of this 
work this definition will be strictly adhered to. There 
should be a wide distinction drawn between these two 
varieties of stricture, for a stricture of large calibre may 
be, and often is, perfectly innocuous, but the baleful 
effects of a stricture of a small calibre are too often made 
manifest. By obstructing the flow of urine it may be the 
starting-point in a series of calamities which not infre- 
quently terminate the existence of the patient, as many a 
surgical kidney can attest. 



CHAPTER XXIII. 

STRICTURE OF THE URETHRA. 

Etiology. 

Stricture of the urethra may be due to a variety of 
causes, chief among which are the following" : 

1. Tonic contraction of the circular muscular fibres of 
the urethra, producing- spasmodic stricture. 

2. Neoplasms and retention cysts which encroach upon 
the lumen of the urethra. 

3. Urethral and peri-urethral exudates, of an inflam- 
matory origin, which have not undergone organization. 

4. Cicatricial contraction following injuries and caustic 
applications. 

5. Gonorrheal infection of the urethra, whicli produces in 
its chronic form a specific type of urethritis whicli goes on to 
the formation of stricture tissue. 

The first three varieties are not, in the strict sense of 
the word, strictures, and as they have but little bearing 
on the subject under discussion they will be considered 
but briefly. Spasmodic stricture is produced by a tonic 
contraction of the circular muscular fibres of the urethra. 
These fibres are present to a marked extent at the apex of 
the prostate gland and in the membranous urethra, where 
they form the external sphincter of the bladder. It is 
the inability to relax at will the sphincteric action of 
these muscular fibres that produces the retention of urine 



STRICTURE OF THE URETHRA. 181 

that is so frequently a concomitant of operations on the 
rectum or perineum. This variety of spasmodic stricture 
is but transitory in its nature and is entirely foreign to 
the subject on which this article is written. True spas- 
modic stricture not due to such causes as the above is 
very rarely met with, and where present it will usually 
be found associated with some pathological condition of 
the urethra, most frequently a granular urethritis with the 
formation of stricture tissue at the site of the spasmodic 
stricture, the latter being merely a muscular spasm en- 
grafted on an organic lesion. A case recently under the 
writer's observation is so typical of this variety of strict- 
ure that it is here briefly reported : 

A gentleman, while still a youth, contracted a gonor- 
rhoea which invaded the posterior urethra and set up a cys- 
titis. After a few months this was followed by retention 
of urine requiring the use of a catheter. Since that time, 
which extends over a period of twenty years, retention has 
been constant. On examination a No. 27 French steel 
sound could be readily passed into the bladder, although 
it was firmly grasped at the bulbo-membranous urethra. 
A No. 5 French soft bougie was grasped with equal firm- 
ness at the same place. To test this point an endoscope 
tube was passed through the stricture and withdrawn un- 
til its extremity rested against the anterior surface of the 
stricture. A filiform bougie was then passed along the 
tube and through the stricture, by which it was tightly 
grasped, demonstrating the presence of a muscular ele- 
ment. The endoscopic examination showed that at this 
situation patches of the urethra had undergone cicatriza- 
tion, and it is probable that it was the irritation due to the 
contraction of the cicatricial tissue on the terminal fila- 
ments of the nerves that caused the spasm of the muscular 



182 DISEASES OF THE URETHRA. 

element of the stricture. External urethrotomy was per- 
formed. The division of the stricture restored at once, 
and permanently, the patient's ability to urinate at will 
without the use of a catheter. 

Strictures resulting* from the encroachment of new 
growths or the formation of retention cysts are not, in the 
strict sense of the word, strictures ; their consideration 
further than the mere mention of their existence would 
be to encroach upon the space intended for the consider- 
ation of subjects more relevant to that under discussion. 
It should not be forgotten, however, that all the obstruc- 
tive symptoms of a true stricture may be present ; and in 
the papillomatous form of tumor there may also be pres- 
ent an obstinate urethral discharge. 

Strictures produced by urethral and peri-urethral ex- 
udates of an inflammatory nature, which have not un- 
dergone organization, are sometimes called soft strict- 
ures, and sometimes inflammatory or irritable strictures. 
They owe their existence to a recent and perhaps still 
active inflammation of the urethra, usually acute gonor- 
rhoea. In acute urethritis the mucous, submucous, and 
occasionally the cavernous tissue is infiltrated with serum 
and leucocytes. In addition the epithelium is stimu- 
lated to increased cell proliferation, the result being a 
urethra with thickened walls and diminished resiliency, 
which may be of such a degree as to narrow the stream 
of urine, and for the time being be classed among the 
strictures of small calibre. On the subsidence of the in- 
flammation the urethra gradually returns, in the majority 
of cases, to its pristine condition, but in a respectable 
minority, resolution may not be complete. A condition 
of chronic infiltration may persist for a time, to either 
ultimately undergo absorption, or, in rare cases, organi- 



STRICTURE OF THE URETHRA. 183 

zatioii, with the production of true stricture. There are 
too many observations confirmatory of the latter change 
to permit of its being controverted, but I venture to pre- 
dict that the pathological investigations of the future 
will show, if it has not already been demonstrated, that 
this process in the formation of true stricture is far from 
being as common as is generally supposed. 

Under the head of traumatic stricture are classed all 
strictures resulting from traumatism, such as direct in- 
juries from without or from within, as by falling astride 
of a rail, or by the unskilful use of instruments, or the 
application of caustic or corrosive injections. When the 
urethra has been subjected to a traumatism of such a 
degree of severity as to lacerate it, a splice of new tissue 
fills the rent and the foundation of a stricture is laid. If 
the rent be small, the plastic material laid down to repair 
the injury may not be sufficient to produce, by its subse- 
quent cicatrization and contraction, a perceptible dimi- 
nution in the expansibility of that portion of the urethra, 
and no stricture results. If, however, the laceration is 
severe, as occurs in complete rupture of the urethra, with 
separation of the torn ends, the resulting cicatrization of 
the new material produces a most intractable stricture, 
which requires the utmost watchfulness and patience in 
order to maintain a sufficient patency of that portion of 
the urethral canal. The rapidity with which this variety of 
stricture forms is astonishing, and is in marked contrast 
to the formation of the next variety of stricture. The 
following case illustrates this rapidity of stricture forma- 
tion : It was a complete rupture of the membranous 
urethra, with extravasation of urine, and was treated by 
retrograde catheterism. A soft catheter was retained in 
the urethra for three days, after which a No. 28 French 



184 DISEASES OF THE UKETHRA. 

steel sound was passed with ease on every alternate day for 
a period of three weeks, when the treatment was abruptly 
terminated by the elopement of the patient from the hos- 
pital. Five weeks later the patient reapplied for treat- 
ment. An examination of his urethra showed that there 
were good reasons for the sincerity of the penitence he 
manifested for his self-imposed curtailment of his treat- 
ment. The cicatrization of the new material that sealed 
the torn ends of the urethra had entirely occluded the 
lumen of the latter. The perineum was riddled by fistu- 
lous opening's, through which micturition was painfully 
accomplished. The upshot was a perineal section and a 
most commendable determination on the part of the 
patient to continue indefinitely, and with the utmost as- 
siduity, the passage of the sounds upon himself. 

The obsolete treatment of breaking a chordee was 
doubtless the parent of many a stricture, although the 
urethral rent must in most cases have been very small. It 
is not uncommon, however, for accidents to the urethra, 
that at the time were considered but trivial, to be pro- 
ductive of strictures, usually of a valvular nature, that 
seriously impede the passage of the urine. 

Tn cases of traumatic .stricture, even where the stricture is 
extensive, a dependent or associated urethral discharge is ex- 
tremely rare. This point will be referred to 'in considera- 
tion of the next and the last variety of stricture, which 
comprises the strictures that are formed by the conver- 
sion of the granulation tissue of chronic urethritis into 
stricture tissue. The pathology of this variety of strict- 
ure has been explained in the chapter on the pathol- 
ogy of chronic anterior urethritis. It will be unneces- 
sary, therefore, to enter into the details of that subject at 
the present time. The reader is simply reminded where 






STRICTURE OF THE URETHRA. 185 

to look for the elucidation of pathological problems that 
in the present chapter may be ignored. 

Strictures due to chronic gonorrhoea comprise the great 
majority of strictures to be met with in the urethra. To 
hazard an estimate at the proportion of all strictures 
which would come under this class, would be to make a 
statement that might be so inaccurate as to be misleading. 
The statement already given, that it preponderates nu- 
merically over all the other varieties of stricture taken 
together, certainly is a safe estimate even if it is indefi- 
nite. 

A chronic urethritis, or a gleet, may exist without the pre- 
existence of a stricture, but the variety of stricture under con- 
sideration cannot exist without the precedence of a chronic 
urethritis, which bears the relationship to the stricture of cause 
and effect. The above assertion is in direct antagonism 
with the views taught by Otis, and is the vital point 
around which so much argumentative literature has cen- 
tred. The teaching of Professor Otis was not only widely 
disseminated, but received a general credence from the 
medical profession of this country, and soon established a 
new school of urethral surgeons. The followers of the 
new and the adherents of the old school of g-enito -urinary 
surgeons were soon engaged in a heated controversy 
which waged for years around the battle-field of stricture 
with varying degrees of success on either side. The two 
schools still stand arraj^ed against each other, although 
the line of demarcation has become less distinct ; many 
of the foremost adherents of the new school have re- 
canted, at least in part, the doctrine they once enthusias- 
tically upheld. The theories promulgated by Otis con- 
cerning the calibre of the urethra, and more especially on 
the causation of gleet, were so antagonistic to those pre- 



186 DISEASES OF THE URETHRA. 

viously entertained, and have had such an important 
bearing on the treatment of both stricture and gleet, that 
they will be entered into somewhat in detail as a prelim- 
inary to their further consideration. Condensed into the 
smallest compass, Otis taught that the normal urethra 
was practically a tube of uniform calibre, which bore a 
definite proportion in size to that of the penis, and that 
any deviation from the uniformity of its calibre whereby 
the dilated urethral canal was narrowed, was not only 
pathological in itself, but was also capable of producing 
or perpetuating a gleet. To quote his own words, in his 
book on " Stricture of the Male Urethra," page 20 : 

" As the urine is propelled through the urethral canal 
it impinges with more or less force upon any contracted 
or salient point. More or less hyperemia necessarily en- 
sues, and a condition is soon established well adapted to 
prolong an existing gonorrhoea, or which, upon slight 
additional cause, such as venereal excitement, or even an 
unusually acrid condition of the urine, may result in the 
origination of a muco-purulent or purulent secretion. We 
mini hence affirm as a mod important axiom that the slight- 
est encroachment upon the calibre of the urethral canal is 
sufficient to perpetuate a urethral discharge, or even, under 
fa coring conditions, establish it (de novo) without venereal 
contact." 

On page 75 of the same work there appears the follow- 
ing : 

" Chronic urethral discharge, commonly called gleet, is 
the signal which nature hangs out to notify the intelli- 
gent surgeon that an obstruction to the normal working 
of the muscular apparatus of the urethra has occurred, 
that plastic material laid down in the antecedent inflam- 
matory condition has begun to contract the normal ure- 
thral calibre, whether it be twenty or forty millimetres 
in circumference, and that nothing short of a complete 



STRICTURE OF THE URETHRA. 187 

restoration of the normal calibre will afford a permanent 
cure. Sandal-oil may stop it for a time, injections of in- 
numerable variety may any one remove it, and thns the 
case goes on getting, as many such cases will affirm, a 
new clap for every woman looked at, until finally an at- 
tack of retention of urine calls attention to the fact that 
the patient has a strictured urethra." 

The teaching of Professor Otis, that gleet owes its ori- 
gin and existence to a stricture, however slight it may 
be, and the natural sequence that the cure of the gleet 
depends on the removal of the obstruction to the passage 
of the urine, reduced the treatment of chronic urethral 
discharge to a very simple basis ; first find the stricture 
and then remove it. The simplicity of this rule, the 
dogmatic manner in which it was enthusiastically taught, 
the mathematical precision of it, as it Avere, by which the 
road to success in urethral surgery was easily trod, con- 
trasted so strikingly with the devious and uncertain 
ways in which the older surgeons taught us to wander, 
that it is not to be wondered at that an army of prac- 
titioners enthusiastically and blindly adopted this rule 
with the result that in the treatment of gleet there has 
been more pernicious activity displayed, more unjustifi- 
able operative interference than in any other department 
of surgery. The American literature on this subject is 
still strongly tainted by the views of Otis, and his disci- 
ples have ample authority behind which to entrench 
themselves in the defence of their views, for it is only 
necessary to refer to the standard works on the subject to 
determine the point in their favor by the weight of au- 
thority. To illustrate what I refer to, I have selected 
the following from the works most frequently used by 
the American practitioner. 



188 DISEASES OF THE URETHRA. 

Holmes's "System of Surgery" (American edition, 
vol. ii.), page 980 : 

" The author does not give sufficient prominence to the 
fact that the vast majority of gleety discharges depend 
upon the presence of stricture." 

Ashhurst's " Text-book of Surgery," sixth edition, page 
1050: 

" One of the earliest symptoms of stricture in many 
cases is the presence of a slight gleety discharge." 

" Diseases of the Urinary and Male Sexual Organs," 
by William T. Belfield, page 90 : 

" That a gleety discharge which has made the usual 
rounds among physicians and has for years resisted med- 
ication by injections and the passage of large sounds (No. 
12 to 16 English) is often maintained by a slight constric- 
tion of the urethral calibre, and completely and imme- 
diately relieved by the division of such constriction, I 
have repeatedly demonstrated." 

" Genito - urinary Diseases with Syphilis," by E. L. 
Keyes, page 135 : 

" This frequency of micturition is the symptom of 
stricture, next to gleety discharge, which is least often 
absent." 

Perhaps the most ardent advocate of the dependence 
of gleet upon stricture that has appeared in recent 
years is G. Frank Lydston, whose work on stricture of 
the urethra, issued during the past year, would almost 
out-Otis Otis. The following is extracted from page 142 
of this work. Speaking of strictures of the pendulous 
urethra, he says : 



STRICTURE OF THE URETHRA. 



189 



" They are a potent cause of chronic urethritis and 
gleet, and explain the obstinacy of very many apparently 
incurable cases of urethral discharge. Even when they 
are not, strictly speaking, the cause of chronic inflamma- 
tion they invariably tend to perpetuate it. If the profes- 
sion had nothing else for which to thank Dr. Otis it 
would be still under lasting obligations to him for his 
demonstration of the true pathological condition in the 
majority of these obstinate cases of gleet which have so 
long been the bete noire of the surgeon." 

To appreciate what Otis considers as coming within 
the limits of stricture, it is necessary to glance at the 
records of his own cases for which he has performed 
urethrotomy, and we shall see frequent illustrations of 
strictures ranging from thirty to thirty -five millimetres. 
In his work on " Stricture of the Male Urethra " he has 
tabulated the number and size of the strictures in one 
hundred and seventy-four cases as follows : 



of Strictures in 
Millimetres. 

1 

H 


Number of 
Strictures. 

1 

1 


Size of Strictures in 
Millimetres. 

23 

24 

25 

26 

27 

28 


Number of 
Strictures. 

18 

36 


2 


1 


44 


3| 


1 


27 


5 


1 


15 


11 


1 

3 

5 


.. 39 


13 

14 


29 

30 

31 

33 


20 

61 

9 

7 


15 

16 


8 

, 3 

1 

11 

15 

12 

8 

19 


17 

18 

19 


34 

35 

36 


18 

9 

5 


20 


38 


1 


21 

22 


39 


1 



The total number of strictures in this table is four 
hundred and one, of which three hundred and twelve, or 



100 



DISEASES OF THE URETHRA. 



about seventy-five per cent., range from twenty-four milli- 
metres upward, and twenty-six per cent, are thirty milli 
metres and upward. Many of the strictures of thirty 
millimetres and upward are only from one to four milli- 
metres smaller than the given size of the urethra. With- 
out stopping to consider the propriety of calling these 
strictures, we must deny most emphatically that they 
would interfere with the passage of a stream of urine by 
acting as a point of increased friction, for even the most 
capacious urethra rarely emits a stream of urine larger 
than a No. 25 French sound, and a fair average of the size 
of the stream of urine may be given as about eighteen 
millimetres in circumference. This estimate, however, is 
given by the writer simply from observation, and not 
from actual measurement. It is difficult to comprehend 
how a stream of urine ranging from fifteen to twenty 
millimetres can be retarded in its passage through a 
urethra which does not manifest points of constriction 
until it is dilated to a size of thirty millimetres or up- 
ward. 
There is a very general misapprehension of the pressure 




Fig. 54. — Diagram Illustrating the Pressure of a Stream of Urine against a 
Stricture. 



exerted against the urethra by the passage of a stream of 
urine. It is generally supposed that where there is an 
obstruction to the passage of a stream of urine, as in 



STRICTURE OF THE URETHRA. 191 

stricture of the urethra, there is an increased pressure 
against the urethral wall at the constricted area. That 
this is an error and that the reverse is true, is capable of 
demonstration by reference to the works on hydraulics 
from which Fig. 54 is taken. 

Let the urethra, for the sake of illustration, be repre- 
sented by the tube a a in Fig. 54, s s representing a 
stricture. It will be found that in the passage of the 
stream the least pressure will be exerted against the 
urethral walls at the strictured area s s, as is shown by 
the height of the water-pressure line, b b. 



CHAPTEE XXIV. 
STRICTURE OF THE URETHRA. 

Symptoms. 

The symptoms of stricture of the urethra vary with the 
nature, size, and location of the stricture. A stricture of 
large calibre, that is, a coarctation of the urethra so wide 
in its calibre that it does not narrow the stream of urine, 
may give negative symptoms. There is an absence of 
frequent micturition, and the stream of urine retains its 
force and volume. There may or may not be a coinci- 
dent urethral discharge ; if present it is not a symptom of 
the stricture, but of a coexisting chronic urethritis, of which 
the stricture is in all probability a sequel. If there is no dis- 
charge it may indicate either that the associated ure- 
thritis is of so mild a grade that its secretion is imper- 
ceptible, although the urine in this case will contain pus 
threads, or else that the antecedent urethritis has under- 
gone a cure by the conversion of the affected area into 
cicatricial tissue ; or, again, the stricture may be the re- 
sultant of a traumatism or of a urethral chancre, in which 
case a chronic urethritis plays no part in the causation of 
the stricture. 

If we are to believe all that is written on the subject, 
strictures of large calibre play an important role in the 
causation of peculiar reflex phenomena. We not infre- 
qiiently hear of the incision of the meatus, or of a strict- 






STRICTURE OF THE URETHRA. 193 

ure of large calibre in the pendulous urethra, giving 
immediate relief to a spasmodic stricture of the deep 
urethra. The explanation given of this phenomenon is 
that the stricture sets up a peripheral irritation of the 
urethral nerves that is manifested by a spasm of the 
deeper muscular structures. So many competent writers 
have recorded their observations on this reflex pheno- 
menon of strictures of large calibre, that the possibility 
of its occurrence must be conceded ; at the same time I 
must confess to never having seen such a case, and time 
and experience serve but to make me sceptical on the 
subject. I fancy that it has happened in many of these 
cases that before the incision of the meatus or stricture a 
small sound was used in an irritable urethra and excited 
a temporary spasm of the muscles by catching on the 
folds of the undilated urethra. The subsequent division 
of the stricture would permit the passage of a larger 
sound and reduce the liability of its being caught, and 
consequently there would be no spasm and an apparent 
cure of an imaginary stricture. I have met with cases 
similar to this where patients had been referred to me 
for the treatment of stricture, the history being that a 
small instrument could not be passed ; on examining the 
patient a large instrument, gently introduced, would 
fairly drop into the bladder. It may be well, in order to 
avoid confusion, to remind the reader that this reference 
to reflex phenomena does not relate to spasmodic stricture 
where there is a combination of organic and muscular 
elements in the same stricture ; but to the reflex pheno- 
mena reputed to be manifested at some point distant from 
the stricture. 

The most varied reflex symptoms have been attributed 
to strictures of large calibre, such as epileptic seizures, 



194 DISEASES OF THE URETHRA. 

paralysis, and various forms of neuralgia. At one time 
there seemed to be a mild form of mania among- physi- 
cians on the subject, but we hear less and less of it as the 
pathology of this and its allied diseases is better under- 
stood. 

To be brief, the symptomatology of stricture of large 
calibre is practically nil, and a careful observer of his 
own case might have such a stricture and yet be totally, 
and we may add happily, oblivious of the fact that any 
permanent pathological changes have taken place in his 
urethra. 

The older writers on the subject had good reasons for 
ignoring this form of stricture, and it is a matter of re- 
gret that the voluminous, and often pernicious, literature 
on the subject renders it necessary to give it considera- 
tion in this article. 

There are two symptoms, not necessarily of stricture, 
that are frequently met with in this class of cases, name- 
ly, dribbling of the urine and forking, twisting, or scatter- 
ing of the stream. The first is due to a rigid, sclerosed 
urethra, the result of an antecedent gonorrhoea, failing to 
collapse and expel the urine it contains until some time 
after the act of urination. The second is due to the 
shape of the meatus. Patients often worry so much 
over this trivial affair that it is well to allay their anxiety 
by an explanation of its mechanism. The meatus is a 
normal point of narrowing, and gives the shape to the 
stream of urine just as the nozzle of a hose gives form to 
its stream. If the nozzle is irregular in outline, so will 
the stream be irregular in outline. If the meatus is par- 
tially sealed, as is often the case in chronic urethritis, 
the stream will probably be irregular in form. Many 
urethra? that are perfectly healthy emit a stream that is 



STRICTURE OF THE URETHRA. 195 

anything but regular ; but let a patient under such cir- 
cumstances contract a urethral disease, and he is prone 
to consider, what he had previously ignored, as a symp- 
tom of the greatest magnitude. It is well, therefore, to 
remember that the form, but not necessarily the force or 
volume, of the stream of urine is derjendent solely on the 
shape of the meatus, and is independent of the deeper 
structures of the urethra. 

Should a stricture of large calibre be treated ? Given 
a urethra with points of contraction capable of detec- 
tion only by instruments which dilate the urethra to a 
greater extent than is exerted by the passage of a 
stream of urine, or, to be more definite, we will say that 
a No. 26 French sound passes without being- obstructed 
in its xDassage, or being held on its withdrawal, also that 
there is no disturbance in the function of micturition, 
should such a urethra be subjected to instrumental or 
other treatment, simply because we have succeeded in 
finding some points in the urethra that are narrower than 
others ? If this is all we have to consider in the case 
there can only be one answer, and that is to leave it 
alone, for its treatment is unnecessary. The mere pres- 
ence of a stricture of large calibre is not of itself a justifica- 
tion for its removal. It is true that by continued con- 
traction it may become a stricture of small calibre, and 
the possible forerunner of a serious malady, but compara- 
tively few of these strictures pursue this course to such 
a termination, and it seems to me that the treatment of a 
stricture of large calibre, merely from a prophylactic 
point of view, would be as unjustifiable as would the re- 
moval of the healthy appendix vermiformis, because it 
serves no useful purpose and might, if left untouched, 
become the source of an appendicitis. 



196 DISEASES OF THE URETHRA. 

It usually happens, however, that strictures of large 
calibre at the time they come under the observation of 
the genito-urinary surgeon are associated with a chronic 
urethritis, for which the patient applies for treatment. 
In the treatment of the latter disease it is often neces- 
sary to use means for its cure that removes at the same 
time the points of narrowing- to which the term stricture 
of large calibre has been given ; but in this case it is not 
the stricture that is the object of treatment, but the asso- 
ciated urethritis, and were the latter cured, and the for- 
mer left intact the result, as far as the patient is con- 
cerned, might be just as good. 

The treatment, therefore, of stricture of large calibre, 
should not be undertaken except where there is an asso- 
ciated disease, such as a chronic urethritis, which then 
becomes the paramount object of treatment. I have for 
Hi is reason chosen to consider its treatment, apart from 
the present article, and have already included it in the 
chapter on the treatment of chronic urethritis. 

The symptoms of stricture of small calibre, that is, a 
coarctation of the urethra, whose calibre is so small that 
it narrows the stream of urine, depends chiefly on the 
amount of obstruction that exists to the passage of the 
urine. In mild cases the patient, if a close observer, will 
simply notice a slight diminution in the force and volume 
of the stream, and a correspondingly greater length of 
time required to empty the bladder. In proportion to 
the degree of obstruction will be the severity of these 
symptoms. Where the obstruction is marked, for in- 
stance, where the stream of urine is the size of a knitting- 
needle or less, frequency of micturition with vesical tenes- 
mus is often a prominent and painful symptom. In these 
cases the urethral obstruction throws increased work on 



STRICTURE OF THE URETHRA. 



197 



the bladder, which either undergoes hypertrophy, with 
diminution of its capacity, or else becomes atonic and 
fails to completely empty itself, and a certain amount of 
urine remains in the bladder. It therefore requires the 
addition of but a little urine in either case to till the blad- 
der and bring - on a renewed attempt to empty itself. In 
extreme cases where the urine escapes drop by drop, 
especially if a cystitis is superadded, we have a picture 
of agony that is pitiable to behold. The patient's entire 
time is devoted to efforts, often futile and always painful, 
to empty his bladder. No sooner has 
he attained momentary relief by the 
passage of a few drops of urine than 
the desire to repeat the effort returns 
with agonizing and uncontrollable 
force, and thus the case goes on from 
bad to worse, until the patient, unless 
relieved, sinks from sheer exhaustion 
or from suppression of urine. 

When a patient has suffered for 
some time from 
urethral obstruc- 
tion, serious 
changes often 
take place, not 
only in the blad- 
der, but also in 
the ureters and 
kidneys. As a re- 
sult Of the re- pjG 55 _ Result of stricture of the Urethra. The 
peated efforts of figure shows the effects upon the bladder, ureter, 

+ V. 11/11 + an( ^ Sidney, of long-standing stricture of the ure- 

tne bladder tO thra (Prom aspecimen in the Middlesex Hospi- 

OVerCOme the Ob- tal Museum. Morris.) 




198 DISEASES OF THE URETHRA. 

struction, the pelvis and ureters are often dilated, the 
latter sometimes to such an extent that the kidney 
substance is thinned out to form a saccular dilatation, 
whose thin walls and atrophied secreting substance 
serve but poorly the purpose for which it was intend- 
ed (Fig-. 55). In a case of this kind, in which I per- 
formed perineal section, I was able to pass a Thomp- 
son's searcher through the perineal opening, into the 
bladder, and along the ureter to the pelvis of the kidney, 
where it could be felt through the abdominal wall. 

If infection of the bladder takes place when the urinary 
tract is in this condition, as may readily happen by the 
use of unclean instruments, infection of the whole urinary 
tract rapidly follows. To the cystitis is then added a 
ureteritis and a p3relonephritis, the onset of which is 
marked by chills and fever ; the urine becomes purulent 
and the patient often dies in a typhoid condition from 
septicaemia or from suppression of urine. 

The urethra also frequently undergoes dilatation and 
thinning at a point immediately posterior to the strict- 
ure, and it not infrequently happens that during some 
expulsive effort a little tear in the mucous membrane 
takes place, through which a few drops of urine are 
forced. This is repeated at the next act of urination ; a 
periurethral abscess results, the skin over the abscess 
breaks down, and a fistulous communication is estab- 
lished with the urethra, at a point posterior to the strict- 
ure through which the urine escapes in whole or in 
part. This is a good illustration of the crude methods 
which Nature sometimes adopts to accomplish her own 
cures. 

A symptom of a close stricture is the inability to ex- 
pel the stream but a short distance, or it may drop di- 



STRICTURE OF THE URETHRA. 199 

rectly from the meatus. The same symptom may be 
present, however, in paretic conditions of the bladder, 
or in obstruction at its neck, as in prostatic hypertrophy. 

A urethral discharge is seldom a concomitant of long- 
standing close strictures, for the reason that a sufficient time 
has usually elapsed for Nature to have effected a cure of the 
antecedent granular urethritis by its conversion into stricture 
tissue. 

A patient who has a stricture of small calibre will fre- 
quently suffer from chills, followed by fever which simu- 
lates malaria except in its rjeriodicity. These cases are 
always grave, since the slightest urethral instrumenta- 
tion may be followed by repeated chills and suppression 
of urine. All these symptoms will usually disappear 
with the removal of the stricture. 



CHAPTER XXV. 

THE LOCATION OF STEICTUBES OF THE URETHRA. 

No part of the urethra is exempt from the possibility 
of stricture formation. Strictures are, however, never 
found in the prostatic urethra, except as the result of 
severe traumatism, such as may be inflicted by the ex- 
traction of large vesical calculi by the median or lateral 
incision. 

The situation in which strictures are most prone to 
be found will depend somewhat on what is our idea of 
stricture. Thus, Sir Henry Thompson found strictures 
much more frequently at the subpubic curvature than 
elsewhere, while Otis found them most frequently near 
the meatus, their number decreasing- with the depth of 
the urethra, and consequently least frequent where Sir 
Henry Thompson found them the oftenest. The latter s 
observations were made from the immense number of 
urethral to be found in the museums of Europe, and, 
consequently, every stricture he observed must have 
contracted the urethra sufficiently to be capable of ocu- 
lar demonstration ; in fact, every stricture must have 
been, according- to the definition in this article, a strict- 
ure of small calibre. On the other hand, Otis gathered 
his statistics mainly from observations made on the liv- 
ing subject, with the urethrometer, so that his list in- 
cludes both strictures of large and those of small calibre. 
Hence the probable cause of the discrepancy between 



LOCATION OF STRICTURES OF THE URETHRA. 201 

these observers, each endeavoring to obtain an accurate 
result, but basing their observations on different methods 
and ideas of stricture, have arrived at radically different 
conclusions. 

If we recognize every irregularity in the dilated ure- 
thra as a stricture, then will we find strictures most fre- 
quently in the pendulous urethra. If, on the other hand, 
we only recognize as strictures points of narrowing that 
diminish the size of the stream of urine, then will we find 
them most often in the bulbo-membranous portion of the 
urethra. There are good anatomical reasons why strict- 
ures should be found most frequently in the latter situa- 
tion, for it is in this situation that the urethral lacunae 
are most numerous, and it is here that the area of great- 
est muscular activity is found, both of which tend to re- 
tard resolution of existing urethral inflammation, and 
predisposes to the localization of the gonorrhceal pro- 
cess, with its consequent formation of granulation tissue 
and subsequent stricture formation. 

Mr. A. P. Gould and Mr. Reginald Harrison attempt to 
explain the frequency of stricture formation in the bul- 
bo-membranous urethra on the supposition "that this 
being a more or less horizontal portion of the urethra, 
the urine and morbid secretions are less liable to be com- 
pletely evacuated and tend to leak through the dam- 
aged urethra." That this hypothesis is tenable will be 
doubted when we reflect that the bulbous portion of the 
urethra is grasped by a muscle whose function is to com- 
pletely empty the urethral canal, and that the posterior 
urethra, owing to its forming, during vesical distention, 
the neck of the bladder, is the part most intimately and 
longest in contact with the urine, yet it is the part of the 
urethra least liable to stricture. 



202 DISEASES OF THE URETHRA. 

In connection with this subject it may be added that a 
number of writers have expressed their belief that when 
the urethra is inflamed it is often denuded, in patches, 
of its epithelium, and as a result the urine tends to leak 
through the mucosa at these places. Nature offsets this 
by laying- down plastic material to act as a barrier to the 
infiltrating urine ; cicatrization of the plastic material 
is liable to ensue, resulting in stricture formation. This 
is at first sight a very plausible theory, but as it leaves 
out of consideration the parasitic cause of the disease, it 
fails to explain the long-continued infectious nature of 
the discharge emanating from the damaged mucosa ; nor 
does it take into consideration that in chronic urethritis 
the epithelial erosions, if present, are almost microscopic 
in size, and that stricture formation does not follow the 
denudation of the epithelium produced by such agencies 
as the endoscopic application of a strong solution of ni- 
trate of silver. 

Tight strictures are usually single, but there may be 
more than one, and if we include strictures of large cali- 
bre in the category, it is possible to find quite a number 
in the same urethra. Otis records a case where there 
were fourteen distinct strictures ; while Thompson says 
that he has never seen more than three or four. In the 
writer's somewhat limited experience he has never seen 
more than two strictures of small calibre in the same 
urethra. 



CHAPTEK XXYI. 

STEICTUEE OF THE URETHRA. 

Treatment of Strictures of Small Calibre. 

How shall we treat a stricture of the urethra ? We have 
a mechanical obstruction to the flow of urine, how shall 
we remove it ? What means shall we adopt that will ac- 
complish this object most satisfactorily and with the least 
risk to the patient ? 

The answers to these questions will depend on three 
factors, namely: the circumstances of the patient, the 
nature of the stricture or strictures, and their location. 
If the patient is in an hospital, time is usually an impor- 
tant object, and we ma} T be justified in adopting- heroic 
measures, as the patient is completely under our control, 
and there is less danger of unfortunate results arising- 
from heroic treatment. Under these circumstances, in 
the great majority of cases urethrotomy would not only 
be justifiable, but be highly proper, as it restores at once 
the calibre of the urethra. Besides many of these cases 
only come to the hospital because immediate relief is 
imperatively necessary. If, however, the patient is com- 
pelled from motives of business or secrecj^ to continue 
during treatment at his daily occupation, then milder 
measures are indicated ; time becomes of less importance, 
and in these cases we have recourse to gradual dilatation 
in preference to urethrotomy. 



204 DISEASES OF THE URETHRA. 

As regards the second factor, the nature of the stricture, 
there are some that are merely mucous folds, or valvular 
strictures, of such feeble resistance that it would be need- 
less surgery to subject the patient to the risks of a 
urethrotomy in order to remove them. Many of these 
strictures are so tight that they seriously obstruct the 
passage of the stream of urine, yet at a single sitting 
they can be dilated to almost the full calibre of the ure- 
thra, by the passage of sounds of progressively increasing 
size. On the other hand, there are many strictures that, 
from their density and unyielding nature, dilate with 
such difficulty that urethrotomy gives the best results. 
Other strictures are resilient or elastic, that is, they yield 
to dilatation with surprising readiness, but contract to 
their pristine closeness almost immediately afterward. 
These strictures are usually situated at the bulbo-mem- 
branous portion and seem to have a muscular as well as a 
fibrous element in them, which may account for their re- 
silient character. This variety of stricture does not yield 
permanently to dilatation, and urethrotomy is indicated. 

Other strictures are, owing to their inflamed condition, 
or to the abnormal sensibility of the patient, acutely 
painful on manipulation. In these cases it is better to 
restore the urethra to its normal calibre at once, by ure- 
throtomy, than to harass the patient by prolonged, pain- 
ful, and generally futile attempts to dilate the stricture, 
which usually results either in increasing its irritation 
and tenderness, or in the patient exhibiting his good 
sense by betaking himself to some other surgeon more 
considerate of his feelings. 

The last factor, the location of the stricture, has an im- 
portant bearing on its treatment. For instance, a stricture 
of the meatus should always be treated by incision, never 



STRICTURE OF THE URETHRA. 205 

by dilatation, while a stricture in the membranous urethra 
is usually best treated by dilatation, unless it is very 
dense or resilient, when an external or a combined ex- 
ternal and internal urethrotomy is to be preferred. 

As a general rule it may be said that the nearer a strict- 
ure is to the meatus the greater the safety of internal 
urethrotomy ; and vice versa, the deeper the stricture the 
greater the danger, consequently, other things being 
equal, the indications for urethrotomy diminish with the 
depth of the stricture. 

There is still another condition that sometimes exerts 
a determining influence on the mode of treatment, and 
that is the condition, not infrequently met with, where, 
from some peculiar nervous susceptibility of the pa- 
tient, or organic disease of the kidneys, the passage of 
the sound is followed by urethral chills and fever, which 
precludes the further use of the sounds and necessitates 
a urethrotomy. The curious fact is often observed that a 
patient will have a severe attack of urethral fever after 
the gentlest passage of the sounds, and yet the same pa- 
tient will stand a urethrotomy and the unkindest sort of 
urethral manipulation without any constitutional disturb- 
ance whatever. 

Bearing in mind the foregoing indications for treat- 
ment we may formulate the rule that, when the urethra 
can he restored to its normal calibre equally as well by means 
of gradual dilatation as by cutting, the preference should be 
given to Hie former on account of its greater safety and free- 
dom from unpleasant sequelce. 

In considering the methods " of treatment I have pur- 
posely omitted to mention two methods in somewhat 
general use, namely, rapid divulsion and electrolysis. 

The former method has a somewhat limited sphere of 



20G DISEASES OF THE URETHRA. 

usefulness iu the rapid divulsion of a tight stricture up 
to a size that will permit of the proper use of the sounds, 
or the urethrotome, as will be indicated when we come 
to the consideration of this variety of stricture. 

The subject of electrolysis is one into which I cannot 
enter with credit to myself, or with justice to either its 
opponents or advocates. My experience with it has been 
nil, but from what I have seen of it in the hands of others 
I am inclined to the belief that the gentle but prolonged 
pressure exerted by the conical-tipped electrode against 
the stricture, has perhaps a more beneficial effect, from a 
mechanical stand-point, than from any electrolytic effect 
to which the entire benefit, if any, is usually ascribed. In 
one case in which the operator Avas baffled in his attempts 
to pass an electrode through a stricture, I succeeded 
Avithout difficulty in passing the same electrode without 
using any electric current whatever. Dr. Robert New- 
man has claimed very good results from this method of 
treating strictures, but others have not been able to obtain 
the same, and many strictures have undoubtedly been 
made worse by it. "We may sum the matter up by saying 
that electrolysis, as a means of treating stricture, has been 
tried and found wanting, and it is needless to trouble the 
reader with a method of treatment that is fast becoming 
obsolete. 

As each urethra is, to a certain extent, a law unto itself, 
and as there are not, and never will be, fixed and unalter- 
able laws to govern its treatment, it would be both absurd 
and useless to attempt to dictate what should be done in 
every case. The general indications for treatment may 
be given, but the exact mode of treatment which should 
be adopted in each case must be left to the discretion of 
the surgeon. He must rely on his own brains just as 



STRICTURE OF THE URETHRA. 207 

much as on the word of authorities. Above all he should 
avoid hobbies, for the man who rides a hobby in urethral 
surgery is a dangerous man. The hobby of indiscrimi- 
nate urethrotomy is particularly dangerous, and has often 
brought disaster on the patient and undeserved disgrace 
on the operation. 

If we will bear in mind what has been said on the treat- 
ment of stricture in the present chapter, and in the chap- 
ter on the treatment of chronic urethritis, it will be un- 
necessary to enter further into the treatment of strictures 
which offer no particular mechanical difficulty— strictures, 
for instance, that will readily permit the passage of a No. 
10 French soft bougie. Such a stricture can be readily 
treated by either gradual dilatation, or dilating ure- 
throtomy, as the operator considers best. 

Strictures whose calibre is so close that the passage of 
any instrument is difficult or impossible often offer very 
serious problems for the surgeon to solve, and on his 
judgment and dexterity frequently depends the life of 
the patient. 

For the purpose of illustration we will suppose that 
we have a case of very tight stricture to treat. What 
should be the modus operandi by which we endeavor to 
overcome it ? In these cases the all-important primary 
object is to pass an instrument through the stricture— no 
matter how small it may be, its passage assures the ulti- 
mate success of the treatment, for the moment we have 
passed an instrument we become the master of the situa- 
tion and no amount of patience and time need be con- 
sidered as wasted if it is rewarded by the passage of the 
stricture. 

The first thing to be done is to attempt to pass a small 
soft bougie ; if it passes, well and good ; if not, it should 



208 DISEASES OF THE URETHRA. 

be immediately withdrawn and a medium-sized conical 
steel sound (No. 24 French) should be passed along the 
urethra until the stricture is reached ; the sound should 
be held firing but gently against the face of the stricture 
for a few minutes. If it be now withdrawn, and is not 
held or grasped by the stricture, it is evident that it is 
unyielding, and that the tip of the sound has not entered 
its lumen. It more often happens, however, that the 
tip of the sound is appreciably held, on the attempt at its 
withdrawal, indicating that it has entered the lumen of 
the stricture. In this case the sound should be reintro- 
duced, and gently but firmly forced against the stricture ; 
counter-traction being made at the same time on the 
penis. This procedure should be steadily kept up for a 
period of ten or fifteen minutes, or longer, if necessary, 
when, if the stricture is not penetrated a sound about two 
millimetres (No. 22 French) smaller should be introduced 
along the tract made by the previous instrument, and the 
same procedure repeated. If this is done patiently and 
firmly, but without violence, it will be surprising how 
often the tightest and densest stricture can be brought 
under control. The philosophy of this method of treat- 
ment is simply that the path of least resistance is along 
the lumen of the stricture, and if we use instruments suf- 
ficiently large to be safe, and employ, not force but firm- 
ness and patience, this path can usually be traversed 
without either danger or difficulty and with the simplest 
appliances. 

Where the stricture is deep in the urethra the passage 
of the sound may be materially assisted, and its position 
assured, by placing the index-finger of the left hand 
within the rectum and against the stricture. By this 
means we become cognizant of the exact position of the 



STRICTURE OF THE URETHRA. 



209 



sound, and if we are familiar with the anatomical relation 
of the parts, the operation can be carried ont with almost 
the accuracy of a dissection, and the formation of a false 
passage guarded against. The formation of a false pas- 
sage indicates that the operator has been a bungler ; that he 
has resorted to violent methods, or the improper use of in- 
struments. Its occurrence bears with it the stamp of con- 
demnation and should not be condoned. It is indicated 
by the sudden slipping forward of the sound, and its 
withdrawal without being grasped or held by the strict- 
ure, the removal of the sound being followed by a free 
hemorrhage. When this unfortunate accident occurs the 
further treatment of the case should be for a time aban- 



PiG. 56.— Filiform bougies. 

doned, until the urethral rent has healed. If urinary ex- 
travasation should take place it should be immediately 
dealt with by free incisions into the infiltrated tissues. 

If we fail in the passage of a sound, a syringeful of 
olive-oil should be injected into the urethra and the fili- 
form bougies tried (Fig. 56). The filiforms should be 
passed one by one, down to the stricture, until eight or 
ten are inserted. Then, taking the filiforms separately 
an attempt is made to insinuate one of them through the 
stricture. A little experience will soon enable the oper- 
ator to tell whether the filiform is passing through or 
merely doubling on itself in front of the stricture. If 
there is a doubt on this point the rotation of the filiform 
will settle it. The unbent filiform rotates readily on its 
own axis, but if bent on itself, the arc its bent extremity 



210 DISEASES OF THE URETHRA. 

describes makes rotations either difficult or impossible. 
A great deal of patience and time may be required in this 
operation, but if it is crowned with success the reward is 
ample. Sometimes it will be advantageous to pass an 
endoscopic tube down to the face of the stricture, and 
observe, if possible, under artificial illumination, the sit- 
uation of the orifice of the stricture, which, in the major- 
ity of cases, will be found nearer the roof than the 
floor of the urethra, on account of the greater liability to 
the formation of granulation tissue in the latter situa- 
tion, and the consequent displacement upward of the 
lumen of the urethra. If the orifice of the stricture can 
be seen, it is sometimes possible to thread a filiform 
through it while it is under observation. The passage of 
the tube as directed will often facilitate the passage of the 
bougies by preventing their entanglement in the folds of 
the urethra and by distending the urethra at the point 
of stricture, which tends to dilate the orifice of the latter. 
Granted that the filiform has been passed, we may con- 
gratulate ourselves on the completion of the most diffi- 
cult and uncertain portion of the operation. We may 
now either retain the filiform in situ for from twenty-four 
to forty-eight hours, trusting to its retention to exert a 




Pig. 57. — Gouley's Modification of Thompson's Divulsor. 



continuous dilatation when a larger bougie will readily 
pass ; or what is preferable, we may pass at once a tun- 
nelled Gouley's or Thonrpson's divulsor (Fig. 57) over 



STRICTURE OF THE URETHRA. 211 

the filiform, using- the latter as a guide to the passage of 
the stricture, and divulse the stricture up to fifteen or 
twenty millimetres, when its further dilatation can be 



&s&4 




Fig. 58. — Maisonneuve's Urethrotome. 

best accomplished by gradual dilatation, or by dilating* 
urethrotomy, as the case may indicate. Of the two 
methods, continuous dilatation and rapid divulsion of 
tight strictures, I prefer the latter ; the former is usually 
tedious and unsatisfactory. 

Some surgeons use the urethrotome in the treatment of 
tight strictures. For this purpose a Maisonneuve's ure- 
throtome (Fig. 58) is used. This instrument is threaded 
through the stricture in a similar manner to the passage 
of the divulsor, and the knife thrust from before back- 
ward. This procedure has but little to recommend itself, 
and has manifest disadvantages. The stricture is not put 
on the stretch at the time of its incision, and the liability 
to injure the healthy mucous membrane is so great that its 
use should be abandoned. We may safely say that the 
addition of this instrument to the surgeon's armamenta- 
rium is, except in very rare cases, unnecessary. No mat- 
ter how tight a stricture may be, it is always pervious, 
unless it is the result of a complete laceration of the 
urethra with discharge of the urine at a point posterior 
to the stricture. It has been said that every stricture 
that is pervious to the passage of urine is also pervious 



212 DISEASES OF THE URETHRA. 

to instruments, consequently every stricture, with the ex- 
ception of the rare impervious ones, can be penetrated bj^ 
the proper use of instruments. This may all be very well 
in theory, but it does not always cany out in practice. 
The very best men have failed to pass a stricture after 
the use of the utmost patience and skill. It has hap- 
pened a number of times in my own practice that I have 
succeeded in passing a stricture with the use of the me- 
dium-sized steel sound after I had failed to pass the fili- 
form bougies. It is for this reason that I have recom- 
mended the use of the sound before resorting to the 
filiforms. 

Strictures that prove impassable for urethral instru- 
ments of any sort are often exceedingly difficult to deal 
with. The patient may be, and usually is, suffering the 
torments of retention of urine. His demands for relief 
are imperative, and justly so, for his life depends upon it. 
To operate on his stricture may prove comparatively easy, 
but, on the other hand, it may be one of the most difficult 
operations that the surgeon can undertake. A good 
light, good assistance, and plenty of time, are requisites 
to its successful completion. If these are not to be had 
we may temporarily relieve the patient by suprapubic 
aspiration of the bladder, which, if the needle is small 
and inserted close to the pubic symphysis, is perfectly 
safe and may be repeated with impunity. Before aspira 
tion came into vogue a trocar and cannula was used ; it was 
inserted either above the pubes or through the recto-vesi- 
cal wall immediately behind the prostate. 

Impassable strictures are usually met with in the bulbo- 
membranous portion of the urethra. Many of them are 
traumatic in origin, and formed of dense, unyielding 
tissue. In these cases an internal urethrotomy is out of 



STRICTURE OF THE URETHRA. 218 

the question, the stricture must be cut from without 
inward by dissection, as we have no guide on which to 
incise the urethra. 

The technique of the operation is as follows : The per- 
ineum and pubes having- been shaved, the patient anaes- 
thetized, and in the lithotomy position, a grooved sound 
is passed along the urethra until its tip rests against the 
stricture. The tip of the instrument should now be 
depressed until it is felt in the perineum, at which point 
it should be exposed by an incision extending directly 
down to it. This incision will open the urethra imme- 
diately in front of the stricture. The margins of the in- 
cised urethra should be secured by two fixation sutures, 
one on either side, and an effort made to find the orifice 
of the stricture. This is often exceedingly difficult, and 
sometimes impossible, owing to the depth of the wound, 
and the difficulty encountered in preventing the blood 
from obscuring the field of operation. If a probe or fili- 
form bougie can be passed it should be used as a guide 
on which to freely incise the stricture. If the orifice of 
the stricture cannot be found an attempt should be made 
to divide it, beginning at the anterior surface of the strict- 
ure, and carefully dissecting toward the bladder, keeping 
in the median line and within the limits of the cicatri- 
cial tissue, in the hope of striking the urethra at a point 
posterior to the stricture. This is a difficult and uncer- 
tain procedure, but with proper precautions is perfectly 
justifiable. It often happens, however^ that we lose our 
landmarks and find that we are working in an unknown 
region, blindly groping in a bloody hole for a ure- 
thra we can neither see nor feel. Under these circum- 
stances the temptation is great to rashly terminate what 
is an embarrassing and dangerous situation, by forcibly 



214 DISEASES OF THE URETHRA. 

accomplishing by foul means what we cannot accom- 
plish by fair ; by thrusting- an instrument blindly on- 
ward in the direction of the bladder, entering the latter 
regardless of the situation of the urethra. Many an 
operation of this kind has been thus brought to an ap- 
parently brilliant termination, and many a patient has 
paid by the sacrifice of his life for this piece of surgical 
malpractice. The surgeon should abandon this opera- 
tion the moment he meets difficulties that he fears may 
prove insurmountable or unduly prolong the operation, 
and in so doing need not feel embarrassed. He may and 
should have immediate recourse to another operation, 
Avhich is much less dangerous than prolonging the search 
for the urethra in the perineal opening. I refer to retro- 
grade catheterism, an operation, the steps of which are 
as definite as those of amputation. This operation is ab- 
solutely void of the uncertainty that attends and makes 
so hazardous the perineal method of operating on im- 
passable stricture. 

The method of operating as performed by the writer is 
as follows : Rectal distention is unnecessary ; the disten- 
tion of the bladder is, of course, not within our control ; 
but even an empty bladder adds but little to the difficul- 
ties of the operation. Antiseptic precautions, it is need- 
less to say, should be rigorously observed. Standing 
on the left side of the patient, avIio should be in the 
Trendelenburg position, the operator should make an 
incision in the middle line, extending from a point half 
an inch below the upper border of the symphysis pubis 
to a point two and a half inches above the pubes. This 
incision should cut through the skin and fascia, exposing 
the muscular aponeurosis. The finger now feels in the 
lower part of the incision for the notch which marks the 



STRICTURE OF THE URETHRA. 215 

upper border of the symphysis pubis. At this point the 
knife is boldly thrust inward until its point is arrested by 
the cartilaginous junction of the pubic bones. It is ad- 
visable to expose this part early in the operation, for it is easy 
to find, and the incision may be carried down to it with a 
total disregard for the abdominal contents. It is also the 
principal landmark in the operation, for it marks not only 
the lowest limit of the deep dissection, and its exposure 
divides the muscular aponeurosis and separates the ten- 
dinous insertion of the recti muscles. The aponeurosis is 
now divided the entire length of the wound, and the recti 
muscles separated with the handle of the scalpel. Re- 
tractors should be used to separate the margin of the 
wound which exposes the transversalis fascia. The right 
index-finger should then be insinuated at the lower angle 
of the wound, hugging closely the inner surface of the pubic 
bones, thus avoiding the peritoneum, which may be disre- 
garded. In sixteen operations of this kind which I have 
performed, I have never in one of them seen the perito- 
neum nor considered myself at any time in dangerous 
proximity to it. 

As the finger approaches the lower border of the sym- 
physis pubis it lies in contact with the anterior surface 
of the bladder, which at this point is covered with fatty 
tissue and a plexus of veins. The fluctuating bladder 
should be distinctly felt. If there is a doubt about it, an 
assistant should pass a finger into the rectum and press 
the bladder forward, which will readily determine its po- 
sition. The bladder- wall is then fixed by thrusting a te- 
naculum through its most prominent part. A narrow- 
bladed knife, cutting edge downward, should be thrust 
into ' the bladder alongside of the tenaculum. The en- 
trance of the knife will be indicated by the esacpe of 



216 DISEASES OF THE URETHRA. 

urine. The vesical incision should be not over a third of 
an inch in length,. just sufficiently large to permit the 
passage of a sound. The moment the incision is made an 
assistant takes the tenaculum, while the operator, with 
the disengaged hand, passes a medium-sized sound be- 
tween the tenaculum and the knife, using the side of the 
latter as a guide. The knife and tenaculum should then 
be withdrawn, and the tip of the sound manoeuvred until 
it enters the vesical orifice of the urethra and its further 
progress arrested by the posterior Avail of the stricture. 
A second sound should be passed along the anterior ure- 
thra until its progress is also arrested by the stricture. 
Between the tips of the two sounds now lies the stricture, 
which should be freely divided from tip to tip, not only 
on the floor, but also on the roof of the urethra. Unsatis- 
factory results are much more liable to accrue from too 
little than from too much cutting of the stricture. The 
urethral channel should be made perfectly free. 

If the operator prefers he may substitute excision of 
the stricture for its division ; in which case he should 
excise the cicatricial mass and retain the ends of the 
urethra in apposition by a row of catgut sutures. 

Having incised the urethra as described, the next step 
of the operation is to insert and retain a catheter in the 
urethra. This is readily accomplished by snipping off 
the tip of a soft rubber catheter and slipping the two 
ends firmly over the tips of the sounds, which present in 
the perineal wound. The sounds should then be with- 
drawn, carrying the tube with them, as is shown in Fig. 
59. The vesical end of the tube should be adjusted so 
that its orifice lies just within the bladder and is retained 
in situ by thrusting a safety-pin first through the pre- 
puce, or lip of the meatus, and then through the tube. 



STRICTURE OF THE URETHRA. 217 

This may seem a barbarous means of fixation, but I have 
seldom had a patient to complain of it, and the absolute 
security of retention that it gives overcomes theoretical 
objections. 

No attempt should be made to suture the bladder. In 
the collapsed condition in which it is retained by the 
drainage of the catheter, the little incision shrinks to still 
smaller proportions, and leakage of the urine does not 




Fig. 59. — Diagram Illustrating the Author's Method of Performing Retrograde 
Catheterism. 

take place. In a comparatively few hours (twenty-four 
to thirty-six) the incision is sealed so that no escape of 
the urine need be feared, even if the bladder is permitted 
to fill. 

The abdominal wound should not be sutured, except at 
its upper and lower angles. A pledget of iodoform gauze 
should be loosely inserted between the lips of the wound 
and down into the prevesical space ; it should be with- 
drawn in two or three days and the wound permitted to 
heal by granulation. 



218 DISEASES OF THE URETHRA. 

The catheter should be retained in the urethra for two 
or three days, or even longer ; its retention favors absorp- 
tion of inflammatory or semi-organized urethral exudates, 
and facilitates the subsequent passage of sounds. 

It may be well to add that this method of treating im- 
passable strictures may often be advantageously applied 
to the treatment of ruptured urethne where similar diffi- 
culties are met with in the catheterization of the bladder. 



INDEX. 



Acute anterior urethritis, abor- 
tive treatment of, 39, 40 

alkalies in, 30 

cause of failure in treatment 
of, 38, 39 

cause of variation in severity 
of, 24, 25 

causes of, 8 

copaiba in, 31 

cubeb in, 32 

how acquired, 16, 17 

incubation period. 17, 18, 19 

injections in, 35, 36, 37 

irrigations in, 34 

local treatment of, 33 

method of extension of, 21 

pathology of, 20, 22 

point of inoculation in, 17 

prescribing in, 32 

routine treatment of, 38, 39 

sandalwood in, 31 

self-limitation of, 24 

sexual intercourse after. 109 

symptoms of, 20, 23, 24 

treatment of, 27, 28, 29 

varieties of, 10 
Acute posterior urethritis, albu- 
min in, 128 

anodynes in, 130 

causes of, 121, 123 

dangers of, 129 

diagnosis of, 127 

frequency of, 122 

frequency of micturition in, 
115, 116, 126, 127 

method of infection of, 21, 114 

nitrate of silver in, 131, 132 

pain of, 128 

period of development of, 125 

symptoms of, 126 

treatment of, 129 

urine in, 127, 128 



Bladder, external sphincter of 
113 
internal sphincter of, 1, 112 

Caput gallinaginis, 116 

Chordee, 99 

Chronic anterior urethritis, causes 

of, 41, 42, 43 
exacerbations of, 64, 65 
infectiousness' of, 107, 108 
localization of, 44, 45 
micturition in, 66 
overtreatment of, 107, 108 
passage of sounds in, 88, 89, 

90, 93 
pathology of, 46, 47, 48, 49, 

50 
resume of treatment of, 102, 

103, 104 
sexual intercourse after, 109, 

110 
symptoms of, 62 
treatment of, 82, 83 
urethrotomy in, 96, 97, 102 
urine in, 62, 63 
use of endoscope in, 104, 105, 

106 
use of nitrate of silver in, 107 
Chronic posterior urethritis, causes 

of, 133, 134 
cooling sound in, 142 
irrigation in, 140 
nitrate of silver in, 140 
passage of sound in, 141 
pathology of, 135, 136 
symptoms of, 137, 138 
treatment of, 139 
Cowper's glands, anatomy of, 143, 

144 
functions of, 145 
Cowperitis, causes of, 145 
relation of, to gleet, 147 



220 



INDEX. 



Cowperitis, symptoms of, 145 
treatment of acute, 145 
treatment of chronic, 147, 148 

Deep urethral syringe, 131 

Endoscope, Desormeaux's, 67 
Grunfeld's, 68 
Klutz's, 68 
Leiter's, 69 
Oberlander's, 69 
Otis's, 69 
Van Antel's, 69 

Endoscopic appearance of the ure- 
thra in health, 75 
of the urethra in disease, 73, 

74 
of the urethral ridges, 74 
of the urethral funnel, 75 

Endoscopy of the urethra, central 
point in, 74 
introduction of the tube in, 71 
method of examination in, 71 
recapitulation of, 76, 77 

Epididymis, anatomy of, 149, 150 

Epididymitis, atrophy of testicle 
following, 156 
causes of, 152, 153 
period of onset of, 153, 154 
recurring, 155, 156 
symptoms of, 154, 155 
treatment of, 157, 158, 159, 160 

External urethrotomy, 213, 214 

Glands of Littre, 5 
Gonococci, description of, 12 

difficulty of examination for, 
15 

discovery of, 9 

examination for, in acute ure- 
thritis, 13 

examination for, in chronic 
urethritis, 14 

where found, 9 

period in which they have 
been found, 110 

vitality of, 12 
Gleet, causes of, 58 

constituents of, 57 

definition of, 56 

description of, 57 

relationship of, to stricture, 58, 
59,60,61,185,186, 187,188, 



Importance of urethral glands 
and lacunae, 7 



Internal urethrotomy, antisepsis 
in, 98 
method of performing, 96, 97 
mortality of, 99, 100 " 
objections to, 99 

Lacuna magna, 6 

Meatotomy, 94, 104 
abuse of, 94, 95 

Micro-organisms found in the ure- 
thra, 10, 11 

Neuralgia of the urethra, 65 
Non-specific urethritis, 10, 26 

Passage of sound, action of, on 

urethral crypts, 93 
as a means of diagnosis, 78, 

88 
as a therapeutic agent, 88, 89, 

90 
method of performing, 84, 85, 

86, 87 
Posterior urethra, anatomy of, 111 
effects of distention of blad- 
der on, 4, 115 
functions of, 111 
muscles of, 2, 112, 113 
nervous supply of, 120 
relation of, to micturition, 114, 

115, 116 
relation of, to sexual system, 

116 

Relation of male and female 
organs of generation, 118, 119, 
120 

Retrograde catheterism, 214, 215, 
216; 217, 218 

Seminal vesicles, anatomy of, 150, 
151 
functions of, 151 
Seminal vesiculitis (acute), causes 
of, 161 
symptoms of, 161, 162 
treatment of, 162, 163 
Seminal vesiculitis (chronic) and 
follicular prostatitis, causes 
of, 165, 166 
impotence in, 168 
pathology of, 166 
sexual disturbance in. 167 
symptoms of, 1 66, 1 67 
treatment of, 169, 170, 171 
Sinus pocularis, 117 



INDEX. 



221 



Spermatic crystals, 168, 169 

Spermatorrhea, 165 

Sterilization of urethral instru- 
ments, 12 

Stricture, anatomy of, 172 

aspiration in retention of urine 

from, 212 
causes of, 180 

continuous dilatation of, 210 
curative effects of urethrot- 
omy on, 97, 98 
dribbling of urine in, 194 
electrolysis in, 206 
false passage in the treatment 

of, 209 
filiform bougies in, 209 
gradual dilatation of, 205 
impassable, 212 
inflammatory, 182 
location of, 200, 201 
micturition in, 192, 196 
mortality of urethrotomy in, 

99, 100, 101 
number of, 202 
resulting from granular ure- 
thritis, 185 
resulting from neoplasms, 182 
passage "of sounds in, 208 
period of formation, 59 
pressure of urine against, 190 
rapid divulsion of, 206, 211 
reflex phenomena of, 192, 193 



Stricture, relation of injections to, 
40 

relation of, to gleet, 58, 59, 60, 
61, 185, 186, 187, 188, 189 

results of, 197, 198 

retrograde catheterism in, 214, 
215, 216, 217, 218 

shape of stream in, 194 

Sir Henry Thompson's defini- 
tion of, 178 

spasmodic, 87, 180 

symptoms of, 192 

Taylor's definition of, 178 

the author's definition of, 179 

table of, 188 

traumatic, 183, 184 

treatment of, 203, 204, 205 

urethrotomy in, 211 

Urethra, anatomy of, 1 

calibre of, 91, 92, 174, 175, 

178 
casts of. 175, 176, 177 
glands of, 5 
lacunae of, 6 
muscles of, 2 

structure of mucous mem- 
brane of, 8 
Urethral mensuration, use of 
sounds in, 78 
use of bulbous bougie in, 79 
use of urethrometer in, 79, 80 



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